Limited to therapeutic (only in case of rape, incest or health of mother)

Limit: 3000.0 Dollars per Episode

Limited to $900 per tooth

Member is responsible for the Primary Care Physician cost share amount when service is performed by a Primary Care Physician or Chiropractor.

Excludes services related to surrogacy if member is not the surrogate.

Limit: 2.0 Visit(s) per Year

Limit: 1.0 Item(s) per 3 Years

Limited to a single purchase of a type of Durable Medical Equipment/Prosthetic (including repair and replacement) every 3 years.

If applicable, copay waived if admitted.

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

30 day supply retail

Limit: 60.0 Visit(s) per Year

20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy

Limit: 1.0 Item(s) per 3 Years

1 hearing aid per ear every 3 years

Limit: 60.0 Visit(s) per Year

Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) ? Limited to a maximum of 60 days per Member, per Calendar Year.

30 day supply retail

Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and 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

20 visit limit for each Physical Therapy, Occupational Therapy and Speech Therapy

30 day supply retail

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. Covered Services also include lead poisoning screening for Dependents under age six (6), as required by state law.

Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and 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: 1.0 Item(s) per 3 Years

Limit is applicable to a single purchase of a type of prosthetic device. Limit does not apply to prosthetics required by the Women?s Health and Cancer Rights Act of 1998.

Limit: 40.0 Visit(s) per Year

20 visits each Physical Therapy/Occupational Therapy per year. Limit is combined across professional visits and outpatient facilities.

Limit: 20.0 Visit(s) per Year

Limit is combined across professional visits and outpatient facilities.

Limit: 1.0 Visit(s) per Year

Limit: 30.0 Days per Admission

Copay is for Primary Care office visit and Specialist Office visits only, other services provided during the visit are subject to deductible and 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.

30 day supply retail

Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth (braces), repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)

Benefits are covered under preventive care.