Copay applies for office visits. All other outpatient benefits will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization.

Limit: 35.0 Visit(s) per Year

Covered only if necessary to improve the function of, or to attempt to create a normal appearance of an abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infection or disease.

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

Limit: 1.0 Item(s) per Year

1 pair of glasses (lenses and frames) per year

Certain services require preauthorization.

If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply.

Limit: 35.0 Visit(s) per Year

Limit: 1.0 Item(s) per 3 Years

To restore or correct impaired speech or hearing loss.

Limit: 60.0 Days per Year

Preauthorization is required.

Diagnosis covered but treatment not covered.

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

Refer to Plan Document for cost associated with certain outpatient laboratory and professional services.

Certain services require preauthorization.

All other outpatient benefits outside of an office visit will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization.

If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply.

Copay waived if provided as preventive care.

Limit: 35.0 Visit(s) per Year

If copay applies, copay amount is for 30 day supply. Copay for 90 day supply is three times the copay for 30 day supply.

No charge for prenatal visits; postnatal visits are covered at the PCP office visit copay.

When pre-approved in a limited set of circumstances under the Home Health Care benefit. Refer to plan document.

Medically necessary foot orthotics are not subject to a calendar year maximum.

Limit: 35.0 Visit(s) per Year

Limit: 35.0 Visit(s) per Year

Limit: 1.0 Exam(s) per Year

Not covered for any services or supplies in connection with routine foot care, including the removal of warts, corns, or calluses. Or the cutting and trimming of toenails, in the absence of diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency.

Limit: 25.0 Days per Year

If copay applies, copay amount is for 30 day supply.

Certain services require preauthorization.

All other outpatient benefits outside of an office visit will pay at the same cost share level as any other medical/surgical benefit. Certain services require preauthorization.

Preauthorization is required.

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

Refer to Plan Document for cost associated with certain outpatient laboratory and professional services.