Treatment must be completed within 12 months of the injury.

Limit: 1.0 Procedure(s) per Lifetime

Exclusions: Procedure(s) per Lifetime

Limit: 1.0 Visit(s) per 6 Months

Exclusions: Visit(s) per 6 Months

Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Limit: 1.0 Visit(s) per 6 Months

Exclusions: Visit(s) per 6 Months

Limit: 8.0 Visit(s) per Year

Exclusions: Visit(s) per Year

Quantity Limit: Two certified diabetes education programs per member per lifetime, and eight visits per benefit year for follow-up training once patient has participated in a diabetes education program.

Limit: 1.0 Item(s) per Year

Exclusions: Item(s) per Year

One frame from the designated pediatric eyewear collection are covered.

Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.

Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services.

Limit: 185.0 Days per Year

Exclusions: Days per Year

Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time.

Major lab and X-ray services may include PET scan, MRI, CT scan, SPECT scan, cardiovascular, nuclear medicine and MRA.

Infusion therapy is covered when provided in the home (home infusion therapy).

Frequency limitations may apply.

Coinsurance will apply for services other than therapy performed in the office or any service at a facility.

Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.

Frequency limitations may apply.

Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services.

Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.

Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Age and frequency limitations may apply

Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services.

Cardiac and pulmonary rehab services from participating providers are coinsurance after deductible and have a 36-visit maximum per plan year. Preauthorization required for all Applied Behavioral Analysis services.

Limit: 1.0 Visit(s) per Year

Exclusions: Visit(s) per Year

One diagnostic exam per calendar year for children under the age of 19 from a VSP provider.

Limit: 100.0 Days per Admission

Exclusions: Days per Admission

100-day confinement limit is for services from participating providers. 60-day confinement limit for services from non-participating providers. Same confinement limit if readmitted with same diagnosis within 60 days.

Certain drugs require preauthorization. The preauthorization for the drug must be approved before the drug will be covered.

Coinsurance will apply for services other than therapy performed in the office or any service at a facility.

Transplants are subject to Case Management.

In-network benefit for services outside of service area. When using Out-of-Network Provider inside service area you may contact the plan to determine if your visit qualifies for in-network benefits.

Age and frequency limitations may apply.