When services are provided in an office setting, cost shares may vary. Please see benefit booklet for details.

Limit: 35.0 Visit(s) per Benefit Period

Muscle manipulations included in Rehabilitation and Habilitation limits.

Except when medically necessary.

Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.

Limit: 1.0 Item(s) per Benefit Period

All frames will first apply towards the allowance. Discount will apply on remaining balance, after the allowance. See benefit book for details

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details.

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

Limit: 1.0 Item(s) per 3 Years

Coverage is limited to 1 hearing aid per ear every 36 month

Limit: 60.0 Visit(s) per Benefit Period

CT scan for heart disease screening. Maximum 1 visit for EDT per every 5 years. Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Member cost share may increase when using a setting other than office. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member cost share may increase when using a setting other than office.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Covered for Preventive and Diabetes services only.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

Member will be responsible for copay per outpatient surgery service before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

Exclusions: Not covered unless medically necessary.

Limit: 35.0 Visit(s) per Benefit Period

Limit includes muscle manipulations.

Limit: 1.0 Visit(s) per Benefit Period

When purchasing Out of Network, reimbursements are available. See benefit book for details.

Covered when medically necessary

Limit: 25.0 Days per Benefit Period

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Sexual Dysfunction, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Member cost share may increase when using a setting other than office. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member cost share may increase when using a setting other than office.

Exclusions: Excludes any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.