Limit: 12.0 Visit(s) per Benefit Period

Member cost share may increase when using a setting other than office. Please see Member Booklet for details.

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

Limit: 10.0 Visit(s) per Benefit Period

Only covered 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.

[Non-HDHP plans] First $250 at 100% of allowable fee, then deductible, copayment, or coinsurance apply. [HDHP plans] After the plan deductible is satisfied, the first $250 will be paid at 100%. Then, standard benefits apply.

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

One pair of glasses (frames and lenses) or one pair of contacts 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 generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details.

Limit: 1.0 Item(s) per 3 Years

1 hearing device every 3 years for dependents age 18 & younger. Medically Necessary cochlear implants may be covered per Medical Policy.

Limit: 180.0 Visit(s) per Benefit Period

Exclusions: Excludes invitro and prescription drugs for the treatment of infertility.

Covered for the diagnosis of infertility and artificial insemination.

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 setting other than office. When services are provided via telehealth or in an outpatient facility setting , cost shares may vary. Please 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 setting other than office. When services are provided via telehealth or in an outpatient facility setting , cost shares may vary. Please see benefit booklet 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.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. 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.

Also covered under preventive health care.

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.

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.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. 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.

When services are provided via telehealth, cost shares may vary. Please see benefit booklet for details.

Limit: 1.0 Visit(s) per Benefit Period

Covered when medically necessary

Limit: 60.0 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. If prescription drugs are bought from an out of network pharmacy additional charges may apply. 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. When services are provided via telehealth or in an outpatient facility setting , cost shares may vary. Please 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 setting other than office. When services are provided via telehealth or in an outpatient facility setting , cost shares may vary. Please see benefit booklet for details.?

Surgical treatment is covered as any other surgery.

Covered for Preventive services only.