SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam
52664OH1530002
Expanded Bronze
HMO
SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam is an Expanded Bronze HMO plan by SummaCare.
IMPORTANT: You are viewing the 2024 version of SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam 52664OH1530002. 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 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam 52664OH1530002.
| Insurer: | SummaCare |
| Network Type: | HMO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 52664OH1530002 |
Cost-Sharing Overview
SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9450 per person | $18900 per group |
| Deductible: | $9450 per person | $18900 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $9,450.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $60.00 |
| Deductible: | $1,600.00 |
| Copayment: | $200.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $2,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
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.
Ready to sign up for SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam?
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Plan Features
SummaCare Bronze 9450 with 3 Free PCP Visits + 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: | No |
| 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 9450 with 3 Free PCP Visits + 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 9450 with 3 Free PCP Visits + 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 | $30.00 Not Applicable | Not Applicable 100.00% | |
| Specialist Visit Covered | Not Applicable 0.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 | $75.00 Not Applicable | $75.00 Not Applicable | |
| Home Health Care Services Covered | Not Applicable 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not Applicable 0.00% 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 0.00% Coinsurance after deductible | Not Applicable 0.00% 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 | $30.00 Not Applicable | Not 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 0.00% Coinsurance after deductible | Not 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 | $30.00 Not Applicable | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | No Charge No Charge | Not 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 Charge | Not 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 Charge | Not 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 0.00% Coinsurance after deductible | Not Applicable 100.00% | 20.0 Visit(s) per Benefit Period |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable 0.00% Coinsurance after deductible | Not 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 Charge | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 0.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not Applicable 100.00% | Benefits include supportive use of an artificial kidney machine |
| Allergy Testing Covered | Not Applicable 0.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 0.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 0.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 0.00% Coinsurance after deductible | Not 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 9450 with 3 Free PCP Visits + 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for SummaCare Bronze 9450 with 3 Free PCP Visits + 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 |
Ready to sign up for SummaCare Bronze 9450 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam?
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