NY State of Health - Standard American Native/Alaskan Indian Plan

Schedule of Benefits
COST-SHARING
Deductible Individual Family Out-of-Pocket Limit Individual Family NONE NONE

Member Cost-Sharing Responsibility for Services from Participating Providers*

NONE NONE

OFFICE VISITS
Primary Care Office Visits (or Home Visits) Specialist Office Visits (or Home Visits)

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full Covered in full

Limits**

PREVENTIVE CARE
Well Child Visits and Immunizations* Adult Annual Physical Examinations* Adult Immunizations* Routine Gynecological Services/Well Woman Exams* Mammography Screenings* Sterilization Procedures for Women* Vasectomy Bone Density Testing* Screening for Prostate Cancer

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Limits

All other preventive services required by USPSTF and Covered in full HRSA. *Preventive services that are provided in accordance with Covered in full the comprehensive guidelines supported by USPSTF and HRSA are covered in full. Preventive services that are provided outside of these guidelines may be subject to costsharing.

EMERGENCY CARE
Pre-Hospital Emergency Medical Services (Ambulance Services)

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full (for services provided from both participating and non-participating providers)

Limits

Non-Emergency Ambulance Services

Covered in full

Emergency Department Coinsurance waived if Hospital admission Urgent Care Center

Covered in full (for services provided from both participating and non-participating providers) Covered in full

NY State of Health - Standard American Native/Alaskan Indian Plan

Schedule of Benefits
PROFESSIONAL SERVICES AND OUTPATIENT CARE
Advanced Imaging Services Performed in a Freestanding Radiology Facility or Office Setting Advanced Imaging Services Performed as Outpatient Hospital Services Allergy Testing & Treatment

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full

Limits

Covered in full Preauthorization Required Covered in full Preauthorization Required

Ambulatory Surgical Center Facility Fee Anesthesia Services (all settings) Autologous Blood Banking Cardiac & Pulmonary Rehabilitation Performed in a Specialist Office Cardiac & Pulmonary Rehabilitation Performed as Outpatient Hospital Services Cardiac & Pulmonary Rehabilitation Performed as Inpatient Hospital Services Chemotherapy Performed in a PCP Office Chemotherapy Performed in a Specialist Office Chemotherapy Performed as Outpatient Hospital Services Chiropractic Services Diagnostic Testing Performed in a PCP Office Diagnostic Testing Performed in a Specialist office Diagnostic Testing Performed as Outpatient Hospital Services Dialysis Performed in a PCP Office Dialysis Performed in a Freestanding Center or Specialist Office Setting Dialysis Performed as Outpatient Hospital Services

Covered in full Preauthorization Required Covered in full Preauthorization Required Covered in full Preauthorization Required Covered in full Covered in full Covered in full Preauthorization Required Covered in full Covered in full Covered in full Preauthorization Required Covered in full Preauthorization Required Covered in full Covered in full Covered in full Preauthorization Required Covered in full (for services provided from both participating and non-participating providers) Covered in full (for services provided from both participating and non-participating providers) Covered in full (for services provided from both participating and non-participating providers) Dialysis Performed by Non-Participating Providers is Covered Only Outside the Service Area and is Limited to 10 Visits Per Calendar Year

Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) Home Health Care Infertility Services Infusion Therapy Performed in a PCP Office Infusion Therapy Performed in Specialist Office Infusion Therapy Performed as Outpatient Hospital Services Infusion Therapy Home Infusion Therapy Inpatient Medical Visits

Covered in full Preauthorization Required Covered in full Preauthorization Required Covered in full Covered in full Covered in full Covered in full Preauthorization Required Covered in full Covered in full

60 visits per condition, per lifetime combined therapies 40 Visits per Plan Year

Home Infusion counts towards Home Health Care Visit Limits

NY State of Health - Standard American Native/Alaskan Indian Plan

Schedule of Benefits
PROFESSIONAL SERVICES AND OUTPATIENT CARE (cont'd)
Laboratory Procedures Performed in a PCP Office Laboratory Procedures Performed in a Freestanding Laboratory Facility or Specialist Office Laboratory Procedures Performed as Outpatient Hospital Services Maternity & Newborn Care Prenatal Care Maternity & Newborn Care Inpatient Hospital Services and Birthing Center Maternity & Newborn Care Physician and Nurse Midwife Services for Delivery Maternity & Newborn Care Breast Pump Outpatient Hospital Surgery Facility Charge Preadmission Testing Diagnostic Radiology Services Performed in a PCP Office Diagnostic Radiology Services Performed in a Freestanding Radiology Facility or Specialist Office Diagnostic Radiology Services Performed as Outpatient Hospital Services Therapeutic Radiology Services Performed in a Freestanding Radiology Facility or Specialist Office Therapeutic Radiology Services Performed as Outpatient Hospital Services Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy)

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full Covered in full

Limits

Covered in full Covered in Full Covered in full Covered in full Covered in Full Preauthorization Required Covered in Full Preauthorization Required Covered in Full Preauthorization Required Covered in full Covered in full Covered for duration of breast feeding

1 Home Care Visit is Covered at no Cost-Sharing if mother is discharged from Hospital early

Covered in Full Preauthorization Required Covered in full

Covered in Full Preauthorization Required Covered in Full Preauthorization Required 60 visits per condition, per lifetime combined therapies Speech and Physical Therapy are only Covered following a Hospital stay or surgery.

Second Opinions on the Diagnosis of Cancer, Surgery & Other

Covered in full

Surgical Services (Including Oral Surgery; Reconstructive Covered in full Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) Inpatient Hospital Surgery Surgical Services (Including Oral Surgery; Reconstructive Covered in full Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) Outpatient Hospital Surgery Surgical Services (Including Oral Surgery; Reconstructive Covered in full Breast Surgery; Other Reconstructive & Corrective Surgery; Transplants; & Interruption of Pregnancy) Surgery Performed at an Ambulatory Surgical Center Surgical Services (Including Oral Surgery; Reconstructive Covered in Full Breast Surgery; Other Reconstructive & Corrective Surgery; Preauthorization Required Transplants; & Interruption of Pregnancy) Office Surgery

NY State of Health - Standard American Native/Alaskan Indian Plan

Schedule of Benefits
ADDITIONAL SERVICES, EQUIPMENT & DEVICES
ABA Treatment for Autism Spectrum Disorder Assistive Communication Devices for Autism Spectrum Disorder

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in Full Preauthorization Required Covered in Full Preauthorization Required

Limits
680 Hours Per Plan Year

Diabetic Equipment, Supplies & Self-Management Covered in full Education Diabetic Equipment, Supplies and Insulin (30-Day Supply) Diabetic Equipment, Supplies & Self-Management Education Diabetic Education Durable Medical Equipment & Braces External Hearing Aids Cochlear Implants Hospice Care Inpatient Hospice Care Outpatient Medical Supplies Prosthetic Devices External Prosthetic Devices Internal Covered in Full Preauthorization Required Covered in Full Preauthorization Required for Items Above $100 Covered in Full Preauthorization Required Covered in Full Preauthorization Required Covered in full Covered in Full Preauthorization Required Covered in Full Preauthorization Required Covered in Full Preauthorization Required Covered in full One prosthetic device, per limb, per lifetime Unlimited 210 Days per Plan Year 5 Visits for Family Bereavement Counseling Single Purchase Once Every 3 Years One Per Ear Per Time Covered

INPATIENT SERVICES & FACILITIES

Inpatient Hospital for a Continuous Confinement (Including an Inpatient Stay for Mastectomy Care, Cardiac & Pulmonary Rehabilitation, & End of Life Care) Observation Stay Skilled Nursing Facility (Includes Cardiac & Pulmonary Rehabilitation) Inpatient Rehabilitation Services (Physical, Speech & Occupational therapy) MENTAL HEALTH & SUBSTANCE USE DISORDER SERVICES

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. Covered in Full Preauthorization Required Covered in Full Preauthorization Required Covered in Full Preauthorization Required

Limits

200 Days Per Plan Year 60 Consecutive Days Per Condition, Per Lifetime

Member Cost-Sharing Responsibility for Services from Participating Providers

Limits

Inpatient Mental Health Care (for a continuous confinement Covered in full when in a Hospital) Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. Outpatient Mental Health Care (Including Partial Hospitalization & Intensive Outpatient Program Services) Inpatient Substance Use Services (for a continuous confinement when in a Hospital) Covered in full

Covered in full Preauthorization Required. However, Preauthorization is Not Required for Emergency Admissions. Covered in full Unlimited; Up to 20 Visits a Plan Year May Be Used For Family Counseling

Outpatient Substance Use Services

PRESCRIPTION DRUGS
Retail Pharmacy 30 Day Supply Tier 1 Tier 2 Tier 3

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full Covered in full Covered in full

Limits

NY State of Health - Standard American Native/Alaskan Indian Plan

Schedule of Benefits
WELLNESS BENEFITS
Gym Reimbursement

Member Cost-Sharing Responsibility for Services from Participating Providers

Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse, not subject to Deductible

Limits
Up to $200 per 6 month period; up to an additional $100 per 6 month period for Spouse

PEDIATRIC DENTAL &VISION CARE***

Pediatric Dental Care Preventive/Routine Dental Care Pediatric Dental Care Major Dental (Endodontics & Prosthodontics) Pediatric Dental Care Orthodontia Pediatric Vision Care Exams Pediatric Vision Care Lenses & Frames Pediatric Vision Care Contact Lenses

Member Cost-Sharing Responsibility for Services from Participating Providers

Covered in full Covered in full Orthodontia & Major Dental Require Preauthorization Covered in full Orthodontia & Major Dental Require Preauthorization Covered in full Covered in full Covered in full Contact Lenses Require Preauthorization

Limits

One Dental Exam & Cleaning Per 6 Month Period

One Exam Per 12-Month Period; One Prescribed Lenses & Frames in a 12 Month Period

*NOTE: Unless otherwise noted, non-participating provider services are not covered and you pay the full cost **NOTE: Additional restrictions may apply. Complete benefit descriptions are available from insurers upon effectuation of coverage. ***NOTE: Not all Standard Plans offer Pediatric Dental Benefits. A Stand-Alone Dental Plan may need to be purchased to receive these benefits. Please refer to the plan details on our website to see if this is included or discuss further with a navigator, broker, or customer service representative.