Covered only in the case of rape or incest, or for a pregnancy which, as certified by a doctor, places the woman in danger of death unless an abortion is performed (i.e., abortions for which federal funding is allowed).

Limit: 3000.0 Dollars per Episode

Limit is combined in network and out of network.

Limit: 12.0 Visit(s) per Year

Limited to Accidental Dental or a Member less than 19 years of age or a Member with intellectual or physical disability, are covered if the Member requires dental treatment to be given in a Hospital or Outpatient Ambulatory Surgical Facility.

Limit: 2.0 Visit(s) per Year

Wigs limited to the first one following cancer treatment.

Non-emergency ambulance/transportation out of network is not covered unless authorized. Authorized out of network is limited to $50,000 per occurrence.

Limit: 1.0 Item(s) per Year

Eye glasses are covered once per benefit period for In Network Services.

Cost share shown is for a 30 day supply.

Limit: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are not combined but separate based on determination of Habilitative Service or Rehabilitative Service) for both in and out of network services.. The limits do not apply to Mental Health and Substance Abuse conditions.

Limit: 100.0 Visit(s) per Year

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

Cost share determined by services rendered.

Cost share shown is for a 30 day supply.

Covered under preventive guidelines and for diabetes. Cost share is driven by provider/setting.

Copay applies to PCP office visit charge only, all other services subject to deductible & coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Limit: 60.0 Visit(s) per Year

Limited to 20 visits each for Rehabilitative Physical, Occupational and Speech Therapy. Limited to 36 visits for Cardiac Rehabilitation. Cost share determined by service rendered.

Cost share shown is for a 30 day supply.

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Copay applies to PCP office visit charge only, all other services subject to deductible & coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Limit: 82.0 Visit(s) per Year

Private Duty Nursing care provided in home setting is limited to a maximum of 82 visits per Member, per Calendar Year and a maximum of 164 visits per Member, per lifetime.

Reconstruction is covered when required following a mastectomy and certain other deformities caused by disease, trauma, congenital anomalies and previous therapeutic process.

Limit: 40.0 Visit(s) per Year

Limited to 20 visits each for Rehabilitative Physical, and Occupational Therapy. Cost share determined by service rendered.

Limit: 20.0 Visit(s) per Year

Cost share determined by services rendered.

Limit: 1.0 Visit(s) per Benefit Period

Eye exams are covered once per benefit period for In Network Services.

Limit: 90.0 Days per Year

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Cost share shown is for a 30 day supply.

Cost share determined by services rendered.

$10,000 limit per transplant for transportation and lodging. Unrelated Donor Search is Limited to a maximum of the 10 best matched donors, identified by an authorized registry.

Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.