BlueExtend PPO Standard Gold - 26065SC0750007 Health Insurance Plan

Limit: 500.0 Dollars per Benefit Period

No Preauthorization is required for the mother's hospitalization related to the delivery of a newborn child when the mother's hospital stay is 48 hours or less for a vaginal birth or 96 hours or less for a cesarean section. Confinements exceeding these limits require Preauthorization.

Diabetes self-management training and education will be provided on an outpatient basis when done by a registered or licensed health care professional that is certified in diabetes.

A replacement DME is covered when due to a change in medical condition.

An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.

Limit: 1.0 Item(s) per Year

Frames and lenses are limited to 1 set per year.

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.

Limit: 30.0 Visit(s) per Benefit Period

Habilitation services are health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Habilitative therapies are combined for a maximum 30 visits per Benefit Period.

Limit: 60.0 Visit(s) per Benefit Period

Limit: 6.0 Months per Episode

The cost sharing that displays applies to outpatient office visits only. All other outpatient services (e.g., intensive outpatient and partial hospitalization programs) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.

Limit: 30.0 Visit(s) per Benefit Period

Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy.

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.

Prenatal and postnatal care will be covered after artificial insemination or in-vitro fertilization, but the actual insemination/fertilization is not covered.

As required by USPSTF, CDC and HRSA, and including OBGYN exams (limit 2 per year), mammography services, pap smear services, prostate services, and routine colorectal cancer screening/testing.

You can save time by consulting a physician using the telehealth service, Blue CareOnDemand. See our brochure or visit www.BlueCareOnDemandSC.com for more details.

Reconstructive Surgery that is considered a Covered Expense is limited to Surgery: To correct a functional defect that results from a birth defect, disease and anomaly; or Performed to correct a seriously disfiguring condition resulting from injury; or For breast reconstruction after a mastectomy.

Limit: 30.0 Visit(s) per Benefit Period

Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy.

Limit: 30.0 Visit(s) per Benefit Period

Physical, speech and occupational rehabilitative therapy are combined for a maximum 30 visits per Benefit Period, other than inpatient therapy.

Limit: 1.0 Exam(s) per Year

Limit: 60.0 Days per Benefit Period

You must be admitted to a Skilled Nursing Facility within 14 days of discharge from an approved hospital admission.

Generic, Brand, and Specialty drugs may be placed on any prescription drug tier. See the Summary of Benefits and Coverage for benefit information on all tiers. Quantity limits or prior authorization are required for some covered drugs. See Covered Drugs List for details.

Services rendered at Doctors Care facilities are provided at in-network Primary Care benefits. An out-of-Network Provider may Balance-Bill you for the difference between the Allowed Amount we pay and their billed charge.