Surgery determined to be Medically Necessary is covered.

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

See plan documents for details on benefit limits.

Limit: 30.0 Visit(s) per Benefit Period

Limit: 20.0 Visit(s) per Episode

Physical Therapy, Occupational Therapy, Osteopathic Manipulation, a Chronic Pain Management Program, and Chiropractic Services limited to 20 combined visits per event. Separate limits from Rehabilitative and Habilitative services.

Limit: 2.0 Visit(s) per Year

Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.

Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition.

Limit: 1.0 Item(s) per Year

Limited to one pair of glasses or contact lenses per benefit year.

Surgery determined to be Medically Necessary is Covered

Select Diabetic Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information.

Limit: 30.0 Visit(s) per Benefit Period

Physical Therapy & Occupational Therapy limited to 30 visits each per benefit period.? Autism Spectrum Disorder Services with limits combined with Habilitative Services.

Limit: 100.0 Visit(s) per Benefit Period

The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy.<br>

Must have a terminal illness with life expectancy of 6 months or less.

The diagnosis and treatment of underlying medical causes of infertility are generally covered, however infertility treatments, such as artificial insemination/invitro fertilization, are not covered.

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

See plan documents for details on benefit limits.

Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.<br>

Diet education covered in the context of diabetes self-management education.

Limited to Medically Necessary Orthodontia. See plan documents for details on benefit limits.

Limit: 30.0 Visit(s) per Benefit Period

Physical Therapy, Occupational Therapy, and Pulmonary Rehabilitation limited to 30 visits each per benefit period.? Cardiac Rehabilitation limited to 36 visits per benefit period.

Limit: 35.0 Visit(s) per Benefit Period

A visit equals 8 hours or less.

(a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence.<br>

Limit: 30.0 Visit(s) per Benefit Period

30 visit each for Occupational and Physical Therapies.

Limit: 2.0 Visit(s) per Year

$1,000 Annual limit combined for all Adult Dental Services. See plan documents for details on benefit limits.

Limit: 1.0 Exam(s) per Year

Quantitative limit units apply, see Summary of Benefits and Coverage.