Includes ABA Therapy. Prior authorization required.

Routine Foot Care and Nutritional Counseling covered based on Medical Necessity.

Benefit depends on place of treatment.

Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise not covered.

Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise not covered.

Limit: 1.0 Item(s) per Year

For children up to age 19. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses are covered for one pair or a single purchase of a supply of contact lenses, including professional services, in lieu of frame and lenses.

Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any Participating Pharmacy or up to a 90 day supply at a 90 day Retail Pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined.

Limit: 30.0 Visit(s) per Year

Some laboratory tests for Diabetes are covered at no charge. Refer to the policy for more information.

This benefit applies to All Other Outpatient Services excluding Office Visits. Please refer to the Specialist Office Visit benefit and to the SBC for more information.

Up to a 30 day supply at any Participating Pharmacy or up to a 90 day supply at a 90 day Retail Pharmacy.

Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined. Services for cardiac and pulmonary rehabilitation have a maximum of 5 visits per calendar year, all services combined.

Up to a 30 day supply at any Participating Pharmacy or up to a 90 day supply at a 90 day Retail Pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Refer to the policy for more information about Virtual Care Services.

Services for physical therapy, occupational therapy and speech therapy have a maximum of 20 visits per calendar year, all services combined.

Services for speech therapy have a 20 visit limit per calendar year combined with physical and occupational therapy.

Limit: 1.0 Exam(s) per Year

For children up to age 19.

Limit: 30.0 Days per Year

Includes Mental Health Office Visits and Substance Use Disorder Office Visits.

Including other high cost drugs. Up to a 30 day supply at any Participating Pharmacy or up to a 30 day supply at a 90 day Retail Pharmacy.

This benefit applies to All Other Outpatient Services excluding Office Visits. Please refer to the Specialist Office Visit benefit and to the SBC for more information.

Lifesource Travel benefit - unlimited, per insured person, per transplant

Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise not covered.