Treatment must be completed within 12 months of the injury.

Limit: 1.0 Procedure(s) per Lifetime

Exclusions: Preauthorization required. No coverage for services without preauthorization

Surgery must be medically necessary. Not all procedures classified as weight reduction surgery are covered. Prior approval for weight reduction surgery is required.

Limit: 1.0 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

Limit: 8.0 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.

Exclusions: Certain durable medical equipment require preauthorization. No coverage for services without preauthorization.

Exclusions: Preauthorization for non-emergency transportation. No coverage for services without preauthorization.

Limit: 1.0 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.

Exclusions: 60-visit limit per plan year for services from non-participating providers. One visit equals a maximum of 4 hours, including private duty nursing.

Limit: 185.0 Days per Year

Exclusions: Some imaging requires preauthorization.

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).

Exclusions: Preauthorization required. No coverage for services without preauthorization

Exclusions: Preauthorization required. No coverage for services without preauthorization

Frequency limitations may apply.

Exclusions: Preauthorization required. No coverage for services without preauthorization.

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.

Plan refers to home skilled nursing as private duty nursing. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting.

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

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

Limit: 100.0 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.

Exclusions: Preauthorization required. No coverage for services without preauthorization.

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.