Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

Limit: 1.0 Visit(s) per 6 Months

Durable medical equipment over $500 requires prior authorization.

Limit: 1.0 Visit(s) per Year

$20 co-pay applies per 30 day supply and $50 co-pay applies per 90 day supply for Generic Drugs on Preventive Drug List. Deductible/Coinsurance for other Generic Drugs, 30-day supply retail; up to 90-day supply home delivery.

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

Limit: 1.0 Item(s) per 3 Years

Prior Authorization required for Inpatient Hospice. Penalties include reduced benefits or denial of claim.

Prior Authorization required for certain Advanced Radiological Imaging services. Penalties include reduced benefits or denial of claim.

Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.

Prior Authorization required (except maternity). Penalties included reduced benefits or denial of claim.

Prior Authorization required. Penalties include reduced benefits or denial of claim.

Benefits are determined by place of service. Benefits displayed are for services received in an office setting; separate benefits may apply for outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim.

$100 co-pay applies per 30 day supply and $250 co-pay applies for 90 day supply for Non-Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Non-Preferred Brand Drugs, 30-day supply retail; up to 90-day supply home delivery. When a Brand Drug is chosen and a Generic Drug equivalent is available, You will pay a Penalty for the difference between the cost of the Brand Drug and the Generic Drug.

Prior Authorization required for Medically Necessary orthodontia. Penalties include reduced benefits or denial of claim.

Prior Authorization required for Outpatient Facility.

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

Prior Authorization required for Outpatient Surgery.

$50 co-pay applies per 30 day supply and $125 co-pay applies per 90 day supply for Preferred Brand Drugs on Preventive Drug List. Deductible/Coinsurance for other Preferred Brand Drugs, 30-day supply retail; up to 90-day supply home delivery. When a Brand Drug is chosen and a Generic Drug equivalent is available, You will pay a Penalty for the difference between the cost of the Brand Drug and the Generic Drug.

Telehealth services are available through Teladoc with your plan.

Limit: 40.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.

Limit: 20.0 Visit(s) per Year

Prior Authorization required for certain therapies. Penalties include reduced benefits or denial of claim.

Limit: 1.0 Visit(s) per Year

Limit: 60.0 Days per Year

Medically Necessary and Appropriate inpatient care requiring medical, rehabilitative or nursing care in a restorative setting. Prior Authorization required. Penalties included reduced benefits or denial of claim.

Up to a 30-day supply. Must use a pharmacy in the preferred specialty pharmacy network.

Prior Authorization required. Penalties include reduced benefits or denial of claim.

Benefits are determined by place of service. Benefits displayed are for services received in an office setting; separate benefits may apply for outpatient services. Prior Authorization required for certain outpatient procedures. Penalties include reduced benefits or denial of claim.

All transplants require Prior Authorization or benefits will be denied. Call our consumer advisors before any pre-transplant evaluation or other transplant service is performed to request Prior Authorization and to obtain information about Transplant Network Providers.

Medically Necessary and Appropriate diagnostic radiology services, including x-rays, ultrasounds and bone density tests. Advanced Radiological Imaging services including MRIs, CT scans, PET scans and nuclear cardiac imaging are covered services, but are subject to different benefits than displayed here. Please refer to the Imaging (CT/PET scans, MRIs) benefit category on healthcare.gov or in the SBC for the appropriate benefits associated with those covered services.