Injury as a result of chewing or biting is not considered an accidental injury.

Bariatric surgery will be available when medically necessary.

$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

Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy.

Cosmetic Procedures do not include coverage for procedures or services that change or improve appearance without significantly improving physiological function, other than those mandated by State or Federal law.

Limit: 2.0 Visit(s) per Benefit Period

See plan documents for details on benefit limits.

Limit: 1.0 Item(s) per Benefit Period

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

Surgery determined to be Medically Necessary is Covered

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy.

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids for members once every 36 months.

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

Limit: 3.0 Treatment(s) per Lifetime

Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.

$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

Nutritional counseling visits are separate from the obesity-related office visits.

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

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for Physical, Occupational, and Manipulation Therapy. Speech Therapy (including Post Cochlear Rehabilitation) limited to 30 visits.

All preventive care that is not state mandated is not covered OON.

Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change after cataract surgery.

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

Limit: 30.0 Visit(s) per Benefit Period

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 Benefit Period

Limit: 1.0 Exam(s) per Benefit Period

Limit: 60.0 Days per Benefit Period

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.