Dental services rendered by a dentist in an office setting which are required as a result of an accidental injury caused by an external force or blow to the jaw, sound natural teeth, mouth or face. Injury as a result of chewing or biting will not be considered an accidental injury. TMJ services would only be covered if accident related. Subject to the professional deductible and coinsurance.

Exclusions: Benefits are not available for clinical ecology, orthomolecular therapy, vitamins, dietary nutritional supplements, or related testing rendered on an outpatient basis. Benefits are not available for the following allergy testing modalities: nasal challenge testing, provocative/neutralization testing, leukocyte histamine release, Rebuck skin window test, passive transfer or Prausnitz- Kustner test, cytotoxic food testing, metabisulfite testing, candidiasis hypersensitivity syndrome testing, IgE level testing for food allergies, general volatile organic screening test and mauve urine test. Benefits are not available for the following methods of desensitization: provocation/neutralization therapy by sublingual (drops) intradermal and subcutaneous routes, urine autoinjections, repository emulsion therapy, candidiasis hypersensitivity syndrome treatment or IV vitamin C therapy.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Limit: 1.0 Procedure(s) per Lifetime

Exclusions: Benefits are NOT available for the Garren gastric bubble technique relating to morbid obesity.

Prior approval is required. Surgeries performed in a hospital are subject to the institutional deductible and coinsurance. Surgeries performed in an ambulatory surgery center are subject to the professional deductible and coinsurance. Surgeries performed in an office setting are subject to the professional deductible with reduced coinsurance to the member.

Subject to the professional deductible and coinsurance. Covers enrolled children through the end of the year in which they turn 19. Coverage Includes minor restorative care, 1 sealant per tooth every 36 months, and certain services classified as endodontic, periodontal, prosthodontic, and oral surgery.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Limit: 15.0 Visit(s) per Year

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Exclusions: No coverage for cosmetic surgery and related services intended primarily to improve appearance.

Prior approval is necessary. Covers expenses related to cosmetic surgery only when restorative surgery is required as the result of a birth defect, accidental injury or a malignant disease process or its treatment. Surgeries performed in a hospital are subject to the institutional deductible and coinsurance. Surgeries performed in an ambulatory surgery center are subject to the professional deductible and coinsurance. Surgeries performed in an office setting are subject to the professional deductible with reduced coinsurance to the member.

Exclusions: Services related to surrogacy

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance. Includes vaginal delivery, caesarean section, miscarriage, complications of pregnancy, circumcisions. Benefits are available for midwives if delivery takes place in a licensed facility. Although, emergency and maternity admissions ARE NOT subject to a sanction,notification to BCBSWY is encouraged.

Limit: 1.0 Visit(s) per 6 Months

Covers enrolled children through the end of the year in which they turn 19. Coverage Includes 1 periodic and 1 comprehensive evaluation every 6 months, bitewing x-rays (up to 4 films every 6 months), 1 cleaning every 6 months, topical application of flouride (2 every 12 months).

Limit: 6.0 Visit(s) per Year

Covered when billed by a participating provider.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Exclusions: Benefits are not available for support devices for the foot, including flat foot conditions. There are no benefits for shoe inserts. Benefits are not available for deluxe motorized equipment, electronic speech aids; robotization devices, robotic prosthetics, dental appliances and artificial organs. Benefits are not available for personal hygiene and convenience items such as air conditioner, humidifiers or physical fitness equipment. Benefits are not available for wigs or artificial hairpieces, or hair transplants or implants, regardless of whether or not there is a medical reason for hair loss.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Includes but not limited to Diabetic supplies, therapeutic devices (e.g. hypodermic needles & syringes), oxygen, onsite and take-home medical/surgical supplies. Benefits are available for rental or purchase, initial fitting/adjustments, repair and replacement, used and refurbished equipment.

Copay applies for each visit before institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Limit: 1.0 Item(s) per Year

Covers enrolled children through the end of the year in which they turn 19, subject to the professional deductible and coinsurance.

Exclusions: Covered surgeries are limited to 1 per lifetime for each specified surgery except when medically necessary due to complications. Cosmetic procedures are not covered services.

Covered services include psychotherapy, hormone therapy, puberty-suppressing medication, laboratory testing to monitor the safety of continues hormone therapy, surgeries as defined in the benefit booklet. Prior approval is required.

Limit: 20.0 Visit(s) per Year

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Speech, occupational, and physical therapy for habilitation are limited to combined maximums of 20 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-habilitation physical therapy is limited to 40 visits per calendar year.

Exclusions: Benefits are not available for services which are primarily non-medical in nature such as bathing, personal grooming, exercising or the administration of medications which can usually be self-administered. Benefits are not available for dietician services, homemaker services, maintenance therapy, food, home delivered meals.

Exclusions: Benefits are not available for donor sperm for artificial insemination or extraordinary procedures to induce fertilization with technical assistance to include surrogate motherhood, gamete intrafallopian transfer, invitro fertilization, peritoneal oocyte and sperm transfer, tubal ovum transfer, artificial insemination, gestational carrier, and preimplantation genetic diagnosis testing.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Covers surgical and medical services on an inpatient or outpatient basis when medically appropriate and necessary and provided by an eligible Professional or Institution to repair or correct the condition causing infertility.

Prior approval is required. Surgeries performed in a hospital are subject to the institutional deductible and coinsurance. Surgeries performed in an ambulatory surgery center are subject to the professional deductible and coinsurance. Surgeries performed in an office setting are subject to the professional deductible with reduced coinsurance to the member.

Exclusions: Benefits are NOT available for inpatient services rendered primarily for diagnostic examinations, physical therapy, rest cure, convalescent care, custodial or sanitaria care. Benefits are NOT available for inpatient care rendered primarily for the purpose of administering allergy, sensitivity, food challenge, or related testing, clinical ecology and vitamins or dietary nutritional supplements.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance. Covers semi private room only and special care unit. When an eligible Professional recommends an inpatient admission, notification to BCBSWY is required prior to services being rendered. Although notices for emergency and maternity admissions ARE NOT required, notification to BCBSWY is encouraged. The preadmission authorization and admission notification provisions do not apply when secondary to Medicare, other health insurance or 3rd party coverage.

Physician services are subject to the professional deductible and coinsurance. Other facility and surgery costs may be subject to the institutional deductible and coinsurance.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Subject to the professional deductible and coinsurance. Covers enrolled children through the end of the year in which they turn 19. Coverage Includes major restorative care, and certain services classified as endodontic, periodontal, prosthodontic, and oral surgery.

Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

If the member chooses a drug from tiers 2-4 when a tier 1 (generic) drug is available, the member must pay the difference in cost between the selected drug and the tier 1 (generic) drug. Subject to the professional deductible and coinsurance.

Subject to the professional deductible and coinsurance. Covers enrolled children through the end of the year in which they turn 19. Covers medically necessary orthodontia only. Precertification required.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Quantitative limit units apply, see specific service (e.g. colonoscopy). Surgeries performed in a hospital are subject to the institutional deductible and coinsurance. Surgeries performed in an ambulatory surgery center are subject to the professional deductible and coinsurance. Surgeries performed in an office setting are subject to the professional deductible with reduced coinsurance to the member.

Limit: 60.0 Visit(s) per Year

Exclusions: No coverage for hypnosis, biofeedback, or pain treatment/therapy.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Quantitative limit units apply, see specific service (e.g. colonoscopy). Physician services are subject to the professional deductible and coinsurance. Other facility and surgery costs may be subject to the institutional deductible and coinsurance. For surgeries performed in an office setting, coinsurance may be reduced.

If the member chooses a drug from tiers 2-4 when a tier 1 (generic) drug is available, the member must pay the copay and the difference in cost between the selected drug and the tier 1 (generic) drug.

Exclusions: Services related to surrogacy

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Includes office visits, appropriate preventive services, and complications.

Exclusions: Only covered when services are rendered by a participating provider.

Preventive care benefits are covered as required under PPACA.

The first 4 office visits are subject to copay. After 4 visits, subject to professional deductible and coinsurance.

Exclusions: Services rendered by a nurse who ordinarily resides in the Member's home or is a member of the Member's immediate family; Services that are provided on an inpatient basis and billed by a hospital; Services which are primarily non-medical in nature, such as bathing, personal grooming, exercising or the administration of medication which can usually be self-administered. Outpatient Private Duty Nursing.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Exclusions: Benefits are not available for deluxe motorized equipment, electronic speech aids; robotization devices, robotic prosthetics, dental appliances and artificial organs.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Exclusions: No coverage for cosmetic surgery and related services intended primarily to improve appearance.

Covers expenses related to cosmetic surgery only when restorative surgery is required as the result of a birth defect, accidental injury or a malignant disease process or its treatment. Prior approval is necessary. Surgeries performed in a hospital are subject to the institutional deductible and coinsurance. Surgeries performed in an ambulatory surgery center are subject to the professional deductible and coinsurance. Surgeries performed in an office setting are subject to the professional deductible with reduced coinsurance to the member.

Limit: 60.0 Visit(s) per Year

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Speech, occupational, and physical therapy for rehabilitation are limited to combined maximums of 60 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-rehabiliation physical therapy is limited to 40 visits per calendar year.

Limit: 60.0 Visit(s) per Year

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Speech, occupational, and physical therapy for rehabilitation are limited to combined maximums of 60 visits per calendar year for outpatient services and 45 days per calendar year for inpatient services. Non-rehabiliation physical therapy is limited to 40 visits per calendar year.

Limit: 1.0 Visit(s) per Year

Covers enrolled children through the end of the year in which they turn 19, subject to the professional deductible and coinsurance.

Prior approval is required. Surgeries performed in a hospital are subject to the institutional deductible and coinsurance. Surgeries performed in an ambulatory surgery center are subject to the professional deductible and coinsurance. Surgeries performed in an office setting are subject to the professional deductible with reduced coinsurance to the member.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Precertification required. If the member chooses a drug from tiers 2-4 when a tier 1 (generic) drug is available, the member must pay the difference in cost between the selected drug and the tier 1 (generic) drug. Subject to the professional deductible and coinsurance.

Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance.

Exclusions: Benefits are NOT available for therapy or counseling services for marital dysfunction or family dysfunction. Benefits are NOT available for the treatment of codependency.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Exclusions: Transportation of the recipient to the location of the transplant surgery. Benefits are NOT available for small intestine, spleen transplantation or donor organs or tissue other than human donor organ or tissue.

Generally subject to the institutional deductible and coinsurance. Physician charges and other related costs may be subject to the professional deductible and coinsurance. Covered but not limited to the following: liver, heart, heart-lung, kidney, pancreas, bone marrow and cornea transplant. Includes evaluation, preparation & delivery of the donor organ; removal of the donor organ; transportation of the donor organ to the location of the transplant surgery; donor search costs.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance.

Exclusions: Benefits are not available for all forms of thermography for all uses and indicators.

Generally subject to the professional deductible and coinsurance. Costs incurred in a hospital setting may be subject to the institutional deductible and coinsurance. Covers CT, MRI, PET scans. PET scans must be preauthorized.