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SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam

52664OH1530033
Bronze
HMO

SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam is a Bronze HMO plan by SummaCare.

IMPORTANT: You are viewing the 2024 version of SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam 52664OH1530033. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam 52664OH1530033.
Insurer: SummaCare
Network Type: HMO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 52664OH1530033

Cost-Sharing Overview

SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
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Plan Features

SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: Yes
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Coverage
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency and Urgent Care Coverage
National Network: No

Additional Benefits and Cost-Sharing

SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Specialist Visit
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilzation; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dsfunction; surgeries or services for sexual transformation,; surgical treatment of flat feet, sugbluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremelty; tretment of telangtiectatic dermal veins; cosmetic surgery; bariatric surgery. See specific exceptions to these exclusions and or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient?s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilzation; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dsfunction; surgeries or services for sexual transformation,; surgical treatment of flat feet, sugbluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremelty; tretment of telangtiectatic dermal veins; cosmetic surgery; bariatric surgery. See specific exceptions to these exclusions and or additional exclusions that are detailed in plan document.
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Infertility treatment is excluded except as required under state law for HMO plans Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 A1h, and must be provided in accordance with Ohio Department of Insurance Bulletin No 2009 07.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Visit(s) per Benefit Period Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit Quantitative Limit has been determined as 90 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.
Routine Eye Exam (Adult)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Visit(s) per Year Routine refraction per year eye exams for medical conditions of the eye.
Urgent Care Centers or Facilities
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%100.0 Visit(s) per Benefit Period Food, housing, homemaker services and home delivered meals; Home or Outpatient hemodialysis services (these are covered under Therapy Services); Physician charges; Helpful environmental materials (hand rails, ramps, telephones, air conditioners, and similar services, appliances and devices); Services provided by registered nurses and other health workers who are not acting as employees or under approved arrangements with a contracting Home Health Care Provider; Services provided by a member of the patient’s immediate family; Services provided by volunteer ambulance associations for which patient is not obligated to pay; visiting teachers, vocational guidance and other counselors, and services related to outside occupational and social activities; Manipulation Therapy services rendered in the home. When therapy services are provided in the home including physical, speech, and occupational therapy as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible For care received in an emergency room, which is not, Emergency Care, including, but not limited to suture removal in an emergency room.
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Non Covered Services for Ambulance include but are not limited to, trips to: a Physician’s office or clinic; a morgue or funeral home; ambulance usage when another type of transportation can be used without endangering the member’s health or any ambulance usage for the convenience of the member, family, or physician; transport by ambulette. Out-of-network ambulance services are excluded except in an emergency or with prior authorization. Ambulance Services are transportation by a vehicle including ground, water, fixed wing and rotary wing air transportation designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians EMT, paramedics, or other certified medical professionals from home, scene of accident or medical emergency to a hospital between hospitals between a hospital and skilled nursing facility or from a hospital or skilled nursing facility to home ambulance trips must be made to the closest facility that can give covered services appropriate for the member’s condition.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. There are specific exceptions to certain exclusions and or additional exclusions that are detailed in plan document inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services and ancillary related services. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Surgical treatment of dental conditions, reversal of voluntary sterilization; radial keratotomy, keratoplasty, Lasik and other surgical procedures to correct refractive defects; surgeries for sexual dysfunction; surgeries or services for sexual transformation; surgical treatment of flat feet, subluxation of the foot, weak, strained, unstable feet, tarsalgia, metatarsalgia, hyperkeratoses; surgical treatment of gynecomastia; treatment of hyperhidrosis; sclerotherapy for treatment of varicose veins of the lower extremity; treatment of telangiectatic dermal veins; cosmetic surgery; bariatric surgery. There are specific exceptions to certain exclusions and or additional exclusions that are detailed in plan document inpatient medical care visits limited to one visit per day by any one physician.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%90.0 Days per Benefit Period Custodial or domiciliary care. Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semiprivate accommodations rehabilitative services and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Includes post delivery follow up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient?s discretion, in a medical setting. This coverage includes, but is not limited to parent education assistance and training in breast or bottle feeding and routine maternal or neonatal tests and screening including collection of sample for hereditary and metabolic newborn screening.
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Custodial or domiciliary Care. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient’s condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Services or care provided or billed by a halfway house, hotel, health resort, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Custodial or domiciliary Care. Room and board charges unless the treatment provided meets medical necessity criteria for Inpatient admission for patient’s condition. Supervised living or halfway houses, services or care provided or billed by a hotel, health resort, convalescent/rest/nursing home, infirmary, or school/special education environment, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included, unless those centers or facilities are required to be covered under state or federal law; marital and sexual counseling/ therapy; and wilderness camps. Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.
Generic Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of one drug in every USP category and class, or the same number of prescription drugs in each USP category and class as the state’s EHB benchmark plan; coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive Screening Immunization benefits.
Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of one drug in every USP category and class, or the same number of prescription drugs in each USP category and class as the state’s EHB benchmark plan coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive or Screening or Immunization benefits.
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of one drug in every USP category and class, or the same number of prescription drugs in each USP category and class as the state’s EHB benchmark plan coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive or Screening or Immunization benefits.
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Drugs for weight loss; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis; over the counter drugs and drugs with over the counter equivalents or nutritional and/or dietary supplements, except where covered under Preventive Care/Screening/Immunization benefits; drugs not approved by the FDA or not requiring a prescription by federal law (except injectable insulin); refills of lost or stolen medications. Must comply with Regulations at 45 C.F.R. 156.122, providing coverage for at least the greater of 1 one drug in every USP category and class, or 2 the same number of prescription drugs in each USP category and class as the state’s EHB benchmark plan coverage must be provided at no cost sharing for over the counter drugs, stop smoking aids, and nutritional or dietary supplements that are required to be covered under the Preventive Screening Immunization benefits.
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%116.0 Visit(s) per Benefit Period Non-Covered Services include: Physical Therapy – maintenance therapy, repetitive exercise, range of motion and passive exercises that are not related to restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse; work hardening. Occupational Therapy – diversional, recreational, vocational therapies and supplies; general exercises to promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Cardiac Rehabilitation – home programs, ongoing conditioning and maintenance. Pulmonary Rehabilitation – services provided in the acute inpatient rehabilitation setting Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below Physical, Occupational and Speech Therapy limited to 20 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Limits may apply to some services includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children 0 to 21, which at a minimum shall include 1 Outpatient Physical Rehabilitation Services including a Speech and Language therapy and or Occupational therapy, 20 visits per year of each service; and b Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week and 2 Mental Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans.
Chiropractic Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%12.0 Visit(s) per Benefit Period Manipulation therapy services rendered in the home as part of Home Care Services. Benefit limit applies for Osteopathic and Chiropractic Manipulation Therapy.
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Items for personal hygiene, environmental control or convenience; exercise equipment; repair and replacement due to misuse, malicious breakage or gross neglect, loss or theft; medical and surgical supplies (usually stocked in the home for general use like- band aids, thermometers, and petroleum jelly); arch supports; doughnut cushions; vitamins; medi-jectors; air conditioners; hot packs; ice bags/ cold pack pump; raised toilet seats; rental of equipment where facility is expected to provide such equipment; trans lift chairs; treadmill exerciser; tub chair; dentures, dental appliances; non-rigid appliances; artificial heart implants; wigs (except following cancer treatment); penile prosthesis in men suffering impotency; orthopedic shoes (except therapeutic shoes for diabetics); foot support devices and corrective shoes, unless they are an integral part of a leg brace; standard elastic stockings and other supplies not specially made and fitted (except as specified under medical supplies); garter belts or similar devices. Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses and contact lenses for cataract surgery or injury and medical and surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period limit of four (4) surgical bras following mastectomy per benefit period (as required by the Women?s Health and Cancer Rights Act) Left Ventricular Artificial Devices LVAD covered only as bridge to heart transplant.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge No ChargeNot Applicable 100.00% Services with an A or B rating from the United States Preventive Services Task Force USPSTF Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention or Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including women?s contraceptives, sterilization procedures, and counseling breastfeeding support, supplies, and counseling benefits for breast pumps are limited to one pump per benefit period and gestational diabetes screening such as routine screening mammograms and routine cytologic screening and child health supervision services from birth to age 9.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge No ChargeNot Applicable 100.00%1.0 Exam(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits
Eye Glasses for Children
Covered
No Charge No ChargeNot Applicable 100.00%1.0 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan including low vision benefits
Dental Check-Up for Children
Not Covered
1.0 Exam(s) per 6 Months Coverage includes benefits specified in the FEDVIP MetLife Federal Dental High Option Plan
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Benefit Period Non-Covered Services include:Physical Therapy – maintenance therapy, repetitive exercise, range of motion and passive exercises that are not relatedto restoration of a specific loss of function; general exercise programs; diathermy, ultrasound and heat treatments for pulmonary conditions; diapulse;work hardening. Occupational Therapy – diversional, recreational, vocational therapies and supplies; general exercisesto promote overall fitness and flexibility; therapy to improve motivation; suction therapy for newborns (feeding machines); soft tissue mobilization (visceral manipulation or visceral soft tissue manipulation), augmented soft tissue mobilization, myofascial; adaptions to the home. Occupational Therapy is limited to 20 visits per benefit period and Physical Therapy is limited to a separate 20 visits per benefit period.
Well Baby Visits and Care
Covered
No Charge No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental High Option Plan.
Orthodontia – Child
Not Covered
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental High Option Plan.
Major Dental Care – Child
Not Covered
Coverage includes benefits specified in the FEDVIP MetLife Federal Dental High Option Plan.
Basic Dental Care – Adult
Not Covered
Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums. See Accidental Dental benefit for additional information
Orthodontia – Adult
Not Covered
Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums. See Accidental Dental benefit for additional information
Major Dental Care – Adult
Not Covered
Adult dental treatment, regardless of origin or cause, is excluded except as specified in the base-benchmark plan when related to accidental injury (limits apply), or for certain services related to transplant preparation, initiation of immunosuppresives, or direct treatment of acute traumatic injury, cancer or cleft palate. Excluded dental treatment includes but is not limited to: Preventive care, diagnosis, treatment of or related to the teeth, jawbones (except that TMJ is a Covered Service) or gums. See Accidental Dental benefit for additional information
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Includes coverage for unrelated donor search services $30,000 per transplant and network and Non network combined and travel and lodging as approved by the plan $10,000 per transplant and network and Non network combined. Transplant benefits apply to any medically necessary human organ and stem cell or bone marrow transplants except cornea and kidney transplants and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation or testing to determine eligibility as a transplant candidate.
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%3000.0 Dollars per Episode Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered. Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law coverage includes oral examinations, x rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular or maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient?s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Benefits include supportive use of an artificial kidney machine
Allergy Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Diabetes Self Management Training for an individual with insulin dependent diabetes, non insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Dentures, replacing teeth or structures directly supporting teeth; Dental appliances; Such non-rigid appliances as elastic stockings, garter belts, arch supports and corsets; Artificial heart implants; Wigs (except following cancer treatment); Penile prosthesis in men suffering impotency resulting from disease or injury. Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that Replace all or part of a missing body part and its adjoining tissues or replace all or part of the function of a permanently useless or malfunctioning body part.
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Home IV therapy includes but is not limited to injections intra-muscular, subcutaneous, continuous subcutaneous, Total Parenteral Nutrition TPN, Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Benefits provided for temporomandibular joint connecting the lower jaw to the temporal bone at the side of the head and craniomandibular head and neck muscle disorders.
Nutritional Counseling
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors.
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Reconstructive services needed as a result of an earlier treatment are covered only if the first treatment would have been a covered service under the plan; coverage for reconstructive services does not apply to orthognathic surgery. Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.
Gender Affirming Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Procedures performed for the sole purpose of improving or altering appearance or self-esteem related to one’s appearance are considered cosmetic in nature, not medically necessary and not covered services. Transexual surgery and related services including pre and post surgery diagnostics, treatments, and drug therapy must be prior authorized and will be covered based upon medical necessity. Cost shares are based on where the transsexual surgery and related services are provided.

Free Preventive Services

There is no copayment or coinsurance for any of the following SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for SummaCare Bronze 8000 with Travel Assistance + Adult Vision Exam including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
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