Land of Lincoln Mutual Health Insurance Company
222 Riverside Plaza, Suite 1900
Chicago, IL 60606
This outline of coverage provides a very brief description of the important features of your Policy. This is not the insurance contract and only the actual Policy provisions will control. The policy itself sets forth in detail the rights and obligations of both You and Your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY!
Policies of this category are designed to provide, to persons insured, coverage for major hospital, medical and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, in-hospital medical services, and out-of-hospital care, subject to any deductibles, copayment provisions or other limitations which may be set forth in the policy. This Policy includes coverage of
Essential Health Benefits (EHB). Basic hospital or basic medical insurance coverage is not provided.
Coinsurance
You pay
Preferred Network
5%
In-Network
30%
Out-of-Network
50%
Deductible Preferred Network/In-Network Out-of-Network
Individual $0 $10,000
Family $0 $20,000
Annual Out-of-
Pocket Maximum
Preferred Network/In-Network Out-of-Network
Individual $600 Unlimited
Family $1,200 Unlimited
Preferred/In-Network Provider
When an Insured Person uses a Preferred or In-Network Provider, Covered Expenses will be subject to the
Preferred and In-Network Deductibles, Coinsurance, Copayments, Out-of-Pocket Maximums and maximum limits for the Covered Expense as stated below.
*NOTE: TO BE ELIGIBLE FOR THE PREFERRED OR IN-NETWORK BENEFITS, YOU MUST CHOOSE A
FAMILY HEALTHCARE NETWORK PRIMARY CARE PHYSICIAN AT THE TIME OF ENROLLMENT. FOR
SERVICES RENDERED OUTSIDE OF YOUR PCP, A REFERRAL FROM YOUR PCP TO A PREFERRED FHN
PROVIDER IS REQUIRED TO RECEIVE THE PREFERRED NETWORK BENEFITS.
Out-of-Network Provider
When an Insured Person uses an Out-of-Network Provider, Covered Expenses will be subject to the Out-of-
Network Deductibles, Coinsurance, Copayments, Out-of-Pocket Maximums and maximum limits for the Covered
Expense as stated below.
Precertification Program
Some Covered Expenses require Precertification. Precertification is required before having any surgical procedures or hospital admissions. When required, an Insured Person or the Insured’s Provider must call the tollfree number shown on the back of an Insured Person’s identification card to obtain Precertification before the service or supply is provided to the Insured Person. If services are determined medically necessary, benefits are subject to Policy provisions and are payable as shown here in this Schedule of Benefits. Failure to comply with
Precertification requirements will result in a $500 reduction of benefits. Covered Expenses that require
Precertification are identified in the Schedule of Benefits.
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I-051S94-OC This Plan is a Qualified Health Plan in the Health Insurance Marketplace.

Benefits
Benefits are payable for Covered Expenses as follows:
Covered Expense
Ambulance
Breast Care
Preferred Network
$400 copay/service
In-Network
$400 copay/service
Mammograms No charge
Mastectomy-Breast $100 copay/day for first
Reconstruction –
Inpatient Hospital Stay
3 days
$10 copay/visit
No charge
$200 copay/day for first 3 days
$20 copay/visit Post Mastectomy Care
– Office Visit
Breast Implant
Removal – Inpatient
Hospital Stay
$100 copay/day for first
3 days. Must be
Medically Necessary.
$200 copay/day for first 3 days. Must be Medically
Necessary.
Out-of-Network
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible.
Must be Medically
Necessary.
5% subject to deductible 30% subject to deductible 50% subject to deductible Durable Medical
Equipment
Emergency Services $400 copay/visit.
Emergency services due to rape or incest are fully covered.
$400 copay/visit.
Emergency services due to rape or incest are fully covered.
$400 copay/visit. Emergency services due to rape or incest are fully covered.
Habilitation Services
Hearing Aids/Cochlear
Implants
Home Health Care
Hospice Care
Hospital Services –
Room and Board including
Miscellaneous Charges and Inpatient Surgery
Maternity/Newborn Care
5% subject to deductible 30% subject to deductible 50% subject to deductible
5% subject to deductible for children under age
30% subject to deductible for children under age 19
50% subject to deductible for children under age 19
19 including one inpatient hearing screening for a newborn. including one inpatient hearing screening for a newborn. Cochlear including one inpatient hearing screening for a newborn. Cochlear implants available every 3 years. Cochlear implants available every 3 years. implants available every 3 years.
$50 copay/visit $200 copay/visit 50% subject to deductible
5% subject to deductible 30% subject to deductible 50% subject to deductible
$100 copay/day for first
3 days
$200 copay/day for first 3 days
50% subject to deductible
$10 copay/visit $20 copay/visit 50% subject to deductible Pre/Post-Natal
Services
Delivery and Inpatient
Services including
Inpatient Newborn
Child Care
Mental/Behavioral
Health – Inpatient
Hospital Stay
Mental/Behavioral
Health – Office Visit
$100 copay/day for first
3 days
$100 copay/day for first
3 days
$10 copay/visit
$200 copay/day for first 3 days
$200 copay/day for first 3 days
$10 copay/visit
50% subject to deductible
50% subject to deductible
50% subject to deductible
Mental/Behavioral
Health – Other
Inpatient and
Outpatient Services
Inpatient Physician
Hospital Visit
Primary Care
Physician Office Visit
5% subject to deductible
5% subject to deductible
$10 copay/visit
Pediatric Dental
Routine Preventive
Exam (Class I)
No charge. Available once every 6 months.
Limited to children under age 19.
Restorative (Class II) 5% subject to deductible. Limited to
30% subject to deductible
30% subject to deductible
$20 copay/visit
No charge. Available once every 6 months. Limited to children under age 19.
30% subject to deductible.
Limited to children under
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible.
Available once every 6 months. Limited to children under age 19.
50% subject to deductible.
Limited to children under
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children under age 19.
Restorative (Class III) 50% subject to deductible. Limited to children under age 19.
Orthodontia (Class IV) 50% subject to deductible. Limited to children under age 19 and must be Medically
Necessary.
Pediatric Vision No charge. Limited to one exam per year and one pair of glasses or contact lenses per year for children under age
19. age 19.
50% subject to deductible.
Limited to children under age 19.
50% subject to deductible.
Limited to children under age 19 and must be
Medically Necessary.
No charge. Limited to one exam per year and one pair of glasses or contact lenses per year for children under age 19. age 19.
50% subject to deductible.
Limited to children under age 19.
50% subject to deductible.
Limited to children under age 19 and must be
Medically Necessary.
50% subject to deductible.
Limited to one exam per year and one pair of glasses or contact lenses per year for children under age 19.
Prescription Drugs
Generic Retail $0 copay/prescription $0 copay/prescription
Preferred Retail $20 copay/prescription $20 copay/prescription
Non-Preferred Retail 5% subject to 5% subject to deductible
Specialty Retail and Mail-Order deductible
5% subject to deductible
5% subject to deductible
Generic Mail-Order $0 copay/prescription $0 copay/prescription
Preferred Mail-Order $50 copay/prescription $50 copay/prescription
Non-Preferred Mail-Order 5% subject to 5% subject to deductible
Preventive/Wellness
Prosthetics/Orthotics deductible
No charge
5% subject to deductible
Radiation/Chemotherapy 5% subject to deductible
Rehabilitation Services –
Inpatient Stay
Rehabilitation Services –
Other Outpatient
Services
$100 copay/day for first 3 days
5% subject to deductible
Second Surgical
Opinions
Skilled Nursing Facility
No charge
$25 copay/day
$100 copay/day for first 3 days
$10 copay/visit
No charge
30% subject to deductible
30% subject to deductible
$200 copay/day for first 3 days
30% subject to deductible 50% subject to deductible
No charge
$100 copay/day
$200 copay/day for first 3 days
$10 copay/visit
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
50% subject to deductible
Substance Use Disorder
– Inpatient Hospital Stay
Substance Use Disorder
– Office Visit
Substance Use Disorder
– Other Inpatient and
Outpatient Services
Therapy Services –
Physical, Occupational, and Speech Therapy
Urgent Care
5% subject to deductible
$10 copay/visit
$50 copay/visit
30% subject to deductible
$20 copay/visit
$50 copay/visit
50% subject to deductible
50% subject to deductible
50% subject to deductible
Organ Transplants are required to use providers in the LLH Transplant Network. Services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this policy are excluded.
Benefits for transportation and lodging are limited to a combined maximum of $10,000 per transplant. The maximum amount that will be provided for lodging is $50 per person per day. In addition, the following are excluded: Cardiac rehabilitation services when not provided to the transplant recipient immediately following discharge from a Hospital for transplant Surgery; travel time and related expenses required by a Provider; drugs which do not have approval of the Food and Drug Administration; storage fees; services provided to any individual who is not the recipient or actual donor, unless otherwise specified in this provision; meals. Precertification required.
Transplant Facility 5% subject to deductible for LLH
Transplant Network providers.
50% subject to deductible for Out-of-
Network providers.
Transplant Physician 5% subject to deductible for LLH 50% subject to deductible for Out-of-
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Transplant Network providers. Network providers.
*NOTE: TO BE ELIGIBLE FOR THE PREFERRED OR IN-NETWORK BENEFITS, YOU MUST CHOOSE A
FAMILY HEALTHCARE NETWORK PRIMARY CARE PHYSICIAN AT THE TIME OF ENROLLMENT. FOR
SERVICES RENDERED OUTSIDE OF YOUR PCP, A REFERRAL FROM YOUR PCP TO A PREFERRED FHN
PROVIDER IS REQUIRED TO RECEIVE THE PREFERRED NETWORK BENEFITS.
No benefits will be paid for:
1. Any service or supply that would be provided without cost to the Insured Person in the absence of insurance covering the service or supply.
2. Expenses/surcharges imposed on an Insured Person by a provider but that are actually the responsibility of the provider to pay.
3. Any services performed by a member of the Insured Person’s immediate family.
4. Any services not identified and included as a Covered Expense under this policy. The Insured Person will be responsible for payment for any services or supplies that are not Covered Expenses.
Even if not specifically excluded in this policy, no benefit will be paid for a service or supply unless it is:
1. Administered or ordered by a Physician; and
2. Medically Necessary to the diagnosis or treatment of an Injury or Illness or covered under the Preventive and Wellness Services provision of this policy.
Covered Expenses will not include and no benefits will be paid for any charges that are incurred:
1. For services or supplies that are provided prior to the Effective Date or after the termination date of this policy.
2. For any portion of the Covered Expense that exceeds the Maximum Allowable Charge.
3. For weight modification including the wiring of teeth.
4. For breast reduction unless Medically Necessary.
5. For breast augmentation.
6. For reversal of sterilization and vasectomies.
7. For abortion unless the life of the mother would be endangered if the fetus were carried to term.
8. For treatment of malocclusions, disorders of the temporomandibular joint, or craniomandibular disorders, except as described in the Jaw-Joint Disorder Treatment provision of this policy.
9. For expenses for television, telephone or expenses for other persons.
10. For marriage, family or child counseling for the treatment of premarital, marriage, family or child relationship dysfunctions.
11. For telephone consultations or for failure to keep a scheduled appointment.
12. For stand-by availability of a Physician when no treatment is rendered.
13. For dental expenses, including braces for any medical or dental condition, surgery and treatment for oral surgery except as provided in the Pediatric Dental or Adult Dental provisions of this policy.
14. For Cosmetic treatment except for reconstructive surgery that is incidental to or follows surgery or an
Injury that is covered by this policy or is performed to correct a birth defect in an insured dependent child.
15. For diagnosis or treatment of attitudinal disorders or disciplinary problems.
16. For charges related to, or in preparation for, tissue or organ transplants except as provided under the
Organ Transplant Services provision.
17. For eye refractive surgery when the primary purpose is to correct nearsightedness, farsightedness or astigmatism, except as provided under the Pediatric Vision provision.
18. While confined primarily to receive rehabilitation, Custodial Care, educational care or nursing services unless expressly provided for under this policy.
19. For vocational or recreational therapy, vocational rehabilitation, outpatient speech therapy or occupational therapy unless expressly provided for under this policy.
20. For alternative or complementary medicine using non-orthodox therapeutic practices that do not follow conventional medicine. These include, but are not limited to: wilderness therapy, outdoor therapy, boot camp, equine therapy, and similar programs.
21. For eyeglasses, contact lenses, hearing aids, eye refraction, visual therapy or for any examination or fitting related to these devices, except as specifically provided for by this policy.
22. For maternity expenses due to pregnancy of an Insured Dependent Child except for Complications of
Pregnancy.
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23. For Experimental or Investigational Treatment or Unproven Services. The fact that an Experimental or
Investigational Treatment or Unproven Service is the only available treatment for a particular condition will not result in benefits if the procedure is considered to be an Experimental or Investigational Treatment or
Unproven Service for the treatment of that particular condition.
24. As a result of Injury or Illness arising out of, or in the course of, employment for wage or profit if the
Insured Person is insured or is required to be insured by workers’ compensation insurance pursuant to applicable state or federal law. If the Insured Person enters into a settlement that waives the Insured
Person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply. In the event that the workers’ compensation insurance carrier denies coverage for an Insured Person’s workers’ compensation claim, this exclusion will still apply unless that denial is appealed to the proper governmental agency and the denial is upheld by that agency.
25. For or related to Durable Medical Equipment or for its fitting, implantation, adjustment, or removal, or for complications therefrom, except as expressly provided under the Durable Medical and Surgical
Equipment provision of this policy.
26. For or related to surrogate parenting.
27. For or related to treatment of hyperhidrosis (excessive sweating).
28. For fetal reduction surgery.
29. For alternative treatments including acupressure, acupuncture, aroma therapy, hypnotism, massage therapy, rolfing and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health.
30. As a result of any Injury sustained at a Residential Treatment Facility.
31. For Prescription Drugs, as of the date of an Insured Person’s enrollment in Medicare Part D.
32. For the following miscellaneous items: artificial insemination except where required by federal or state law; biofeedback; care or complications resulting from non-covered expenses; chelating agents; domiciliary care; food and food supplements; foot care (with the exception of persons with diabetes); foot orthotics or corrective shoes; health club memberships; home test kits; care or services provided to a non-insured biological parent; nutrition or dietary supplements; pre-marital lab work; processing fees; private duty nursing; rehabilitation services for the enhancement of job, athletic or recreational performance; routine or elective care outside the service area; sclerotherapy for varicose veins; treatment of spider veins; programs or services except where required by federal or state law; transportation expenses unless specifically covered by this policy.
33. Services or supplies eligible for payment under either federal or state programs (except Medicaid). This exclusion applies whether or not the Insured Person asserts his or her rights to obtain this coverage or payment of these services.
34. Weight loss programs that promote healthy diet habits for the sole basis of losing weight.
35. Services or supplies for long term custodial care.
The following limitations apply to the Outpatient Prescription Drug Program: x Certain drugs may be limited by the quantity of the drug covered by this policy. Limitations may be for how much of the drug You may receive each time You fill a prescription or the number of refills that can be obtained. x A network pharmacy may refuse to fill a prescription order or refill when in the professional judgment of the pharmacist the prescription should not be filled. x This policy will not cover expenses for any Prescription Drug for which the actual charge to You is less than the required Copayment or Deductible, or for any Prescription Drug for which no charge is made to
You. x You will be charged the out-of-network Prescription Drug cost sharing for Prescription Drugs recently approved by the FDA, but which have not yet been reviewed by the LLH Health Pharmacy Management
Department and Therapeutics Committee. x LLH retains the right to review all requests for reimbursement and in its reasonable authority make reimbursement determinations subject to the Complaint and Appeals section(s) of the policy. x In some cases, You may be required to use Step Therapy in the administration of a drug. This means
You will be required to first try certain drugs to treat Your medical condition before another drug for that condition is covered.
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Not every health care service or supply is covered by this policy, even if prescribed, recommended, or approved by an Insured Person’s Physician. This policy covers only those services and supplies that are Medically
Necessary. This section describes expenses that are not covered or subject to special limitations.
These Prescription Drug exclusions are in addition to the exclusions listed under Your medical coverage. This policy does not cover the following expenses: x
Any charges in excess of the benefit, maximum, allowable charge, days or supply limits stated in this policy. x Any non-emergency charges incurred outside of the United States if 1) You traveled to such location to obtain Prescription Drugs, or supplies, even if otherwise covered under this policy, or 2) such drugs or supplies are unavailable or illegal in the United States, or 3) the purchase of such Prescription Drugs or supplies outside the United States is considered illegal. x Any drugs or medications, services and supplies that are not Medically Necessary for the diagnosis, care or treatment of the Illness or Injury involved. x Cosmetic drugs, medications or preparations used primarily to enhance appearance including, but not limited to, health and beauty aids, chemical peels, dermabrasion, treatments, bleaching, creams, ointments or other treatments or supplies, to remove tattoos, scars or to alter the appearance or texture of the skin (for example the correction of skin wrinkles and skin aging). x
Over the counter drugs unless a prescription for such drug is provided by Your Physician. x
All drugs or medications in a therapeutic drug class that is not part of the Formulary. x Drugs that the use of or intended use of, would be illegal, unethical, imprudent, abusive, not Medically
Necessary, or otherwise, improper. x Drugs obtained by unauthorized, fraudulent, abusive, or improper use of the identification card. x Experimental or Investigational drugs or devices. x Food items: Any food item, including infant formulas, nutritional supplements, vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition except for amino acid-based elemental formula that is medically necessary for the diagnosis and treatment of eosinophilic disorders and short bowel syndrome. x Vitamins (except those vitamins prescribed by a Physician). x Genetics: Any treatment, device, drug, or supply to alter the body’s genes, genetic make-up, or the expression of the body’s genes except for the correction of congenital birth defects. x Needles and syringes, except for prescribed medications. x Prescription Drugs for which there is an over-the-counter (OTC) product which has the same active ingredient and strength unless a prescription is written. x Prescription orders filled prior to the Effective Date or after the termination date of coverage under this policy. x Prophylactic drugs for travel except for the prevention of Malaria. x Refills in excess of the amount specified by the prescription order. Before recognizing charges, LLH may require a new prescription or evidence as to need, if a prescription or refill appears excessive under accepted medical practice standards.
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x Refills dispensed more than one year from the date the latest prescription order was written, or as otherwise permitted by applicable law of the jurisdiction in which the drug is dispensed. x Replacement of lost or stolen prescriptions. x Rogaine, minoxidil, or any other drugs, medications, solutions, or preparations used or intended for use in the treatment of hair loss, hair thinning, or any related condition, whether to facilitate or promote hair growth, to replace lost hair, or otherwise. x Covered drugs, devices, or other Pharmacy services or supplies provided or available in connection with an Occupational Illness or Injury sustained in the scope of and in the course of employment if such benefits are provided under the Worker’s Compensation law. x Any special services provided by the Pharmacy, including but not limited to, counseling and delivery. x Drugs which are repackaged by a company other than the original manufacturer. x Drugs which are not approved by the FDA for a particular use or purpose, or when used for a purpose other than the purpose for which the FDA approval is given, except as required by law or regulation. x Some equivalent drugs manufactured under multiple Brand Names. Benefits may be limited to only one of the brand equivalents available. x Drugs or preparations, devices and supplies to enhance strength, physical condition, endurance or physical performance, including performance enhancing steroids.
Your coverage under this Policy will terminate on the date of the first of the following to occur:
2. Subject to the Grace Period, non-payment of the required premium when due. Termination will be effective on the last day for which premium was paid.
3. You commit fraud or make an intentional misrepresentation of a material fact. LLH will provide 30-day advance written notice of the date of termination.
4. You fail to comply with the policy provisions. Termination will be effective at 12:01 a.m. local time at Your address on the date of the occurrence.
5. You enter full-time military, naval or air service.
6. You move outside the service area.
7. You enroll in another health insurance plan during an Open Enrollment Period.
8. You request termination of the policy in writing. Termination will be effective at the end of the billing period in which the requested termination date occurs.
9. LLH has a right or defense to take such action.
10. LLH ceases to offer this type of plan or ceases to do business in the individual medical market as allowed by state law. If LLH discontinues a particular individual health plan, LLH will provide 90 days prior notification to You of such discontinuance and will offer the option to purchase another type of plan then being offered at that time.
11. If coverage was purchased through an Exchange: a. You cease to be eligible for coverage through the Exchange; or b. The policy ceases to be a Qualified Health Plan and is decertified by the Exchange. The
Exchange will initiate the termination and notify LLH of the event. The termination date will be assigned.
An Insured Dependent’s coverage will terminate under the policy on the first of the following to occur:
1. The Insured Dependent’s death.
2. When an Insured Dependent no longer qualifies as an eligible Dependent.
3. The date an Insured Dependent is no longer a resident of the service area.
4. An Insured Dependent enrolls in another health insurance plan during an Open Enrollment Period.
5. An Insured Dependent enters full-time military, naval or air service.
6. An Insured Dependent commits fraud or makes an intentional misrepresentation of a material fact. LLH will provide 30-day advance written notice of the date of termination.
7. The date the policy terminates.
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8. If coverage was purchased through an Exchange: a. An Insured Dependent ceases to be eligible for coverage through the Exchange; or b. This policy ceases to be a Qualified Health Plan and is decertified by the Exchange. The
Exchange will initiate the termination and notify LLH of the event. The termination date will be assigned.
9. An Insured Dependent Child attains the limiting age. However, an Insured Dependent Child’s coverage will not terminate if the Child is: a. Not capable of self-sustaining employment due to mental or physical handicap that began before the age limit was reached; and b. Mainly dependent on You for support.
You are responsible for notifying LLH of any of the events stated above that would result in termination of coverage.
LLH will renew or continue coverage at Your option. Such guaranteed renewability is not applicable in cases of nonpayment of premium, fraud or intentional misrepresentation, and termination of coverage. Network plans may non-renew coverage if there are no enrollees who live, reside or work in the service area. Applicable terms also apply to uniform termination of coverage.
If this policy has lapsed and You request renewal, LLH may accept this request without the original step of filling out a new application. This conditional renewed policy will be reviewed by LLH and if not accepted will inform You in writing of the final decision within 45 days of receipt of the policy premium. Upon receipt of the policy premium, the lapsed policy will reinstate in full 45 days following the conditional renewal unless previously declined, in writing. The reinstated policy shall cover claims resulting from Injury or Illness 10 days after the date of reinstatement. In all other respects, You and LLH shall have the same rights under the policy as before the due date of the defaulted premium. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement.
If an Insured Person’s coverage under this policy has been interrupted by a period of military service in the armed forces of the United States or by coverage for dependents of military personnel under a federally governmentsponsored health insurance program, such persons shall be entitled to reinstatement under this policy upon discharge from such military service or termination of coverage under the federally sponsored health insurance program. Request for reinstatement and payment of premium must be made to LLH within 63 days after discharge.
Reinstatement is not available to a person or his or her dependents if the person is discharged due to less than honorable conditions or if such person no longer satisfies the requirements of the ELIGIBILITY provision of this policy.
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