Cost sharing and limitation depend on type and site of service. Limited to treatment for a Dental Injury to a Sound Natural Tooth.

Cost sharing depends on type and site of service.

Cost sharing depends on type and site of service. Injectable chemotherapeutic agents require preauthorization.

Limit: 35.0 Visit(s) per Year

Limited to combined 35 visits per year, including Chiropractic.

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

Cost sharing depends on type and site of service.

Cost sharing depends on type and site of service.

Certain services require preauthorization (DME over $500).

Exclusions: Travel or ambulance services for convenience.

Prior authorization is required for out of network ambulance services, out of area transfers, non-emergency ground transportation, air transportation, and facility to facility transfers.

Limit: 1.0 Item(s) per Year

For select frames, standard lenses, and contact lenses only.

Subject to formulary requirements and preauthorization may be required (when generic is not the preferred agent).

Cost sharing depends on type and site of service. Limited to medical necessity. Prior authorization is required.

Limit: 1.0 Item(s) per 3 Years

To restore or correction of impaired speech or hearing loss. Each ear, every 3 years. Prior authorization is required.

Limit: 60.0 Visit(s) per Year

Prior authorization is required.

Cost sharing and limitations depend on type and site of service.

Preauthorization is required.

Cost sharing and limitation depend on type and site of service. Preauthorization is required.

Prior authorization is required.

Prior authorization is required for inpatient surgical services.

Some services require preauthorization.

Preauthorization is required.

Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.

Subject to formulary requirements and preauthorization may be required.

Preauthorization is required. Cost sharing depends on type and site of service.

Cost sharing and limitations depend on type and site of service.

Cost sharing and limitations depend on type and site of service.

Limited to Medically Necessary outpatient Rehabilitative Therapy visits to or by a Participating Provider other than a Primary Care Physician. Prior authorization is required.

Outpatient services and Habilitation Services are subject to different cost-sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance. Preauthorization is required for outpatient surgeries.

Subject to formulary requirements and preauthorization may be required.

Inpatient private duty nursing.

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

Cost sharing depends on type and site of service. Proton beam radiation requires preauthorization.

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. Preauthorization is required. Cost sharing depends on type and site of service.

Prior authorization is required. Limited to medical necessity.

Prior authorization is required. Limited to medical necessity.

Limit: 1.0 Visit(s) per Year

Covered services for children 18 and under.

Coverage for foot care is limited to members with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency is covered. 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 are excluded. Cost sharing and limitations depend on site of service.

Limit: 25.0 Days per Year

Cost sharing and limitation depend on type and site of service. Prior authorization is required.

Subject to formulary requirements and preauthorization may be required.

Preauthorization is required.

Certain services require preauthorization. Cost sharing depends on type and site of service. This benefit (Mental/Behavioral Health Outpatient Services, Substance Abuse Disorder Outpatient Services, and Habilitation Services) is subject to different cost sharing depending on whether the service is an office visit or other outpatient service. Office visits are subject to copays, while facility-based services are subject to coinsurance.

Exclusions: Subject to the conditions described below, benefits for covered services and supplies provided to a Participant by a Hospital, Physician, or Other Provider related to an organ or tissue transplant will be determined as follows, but only if all the following conditions are met: The transplant procedure is not Experimental/Investigational in nature; and Donated human organs or tissue or an FDA-approved artificial device are used; and The recipient is a Participant under the Plan; and The transplant procedure is preauthorized as required under the Plan; and The Participant meets all of the criteria established by CHC in pertinent written medical policies; and The Participant meets all of the protocols established by the Hospital in which the transplant is performed. Donor expenses for a Participant in connection with an organ or tissue transplant is not a covered benefit if the recipient is not covered under this Plan. No benefits are available for any organ or tissue transplant procedure, or services performed in preparation for, or in conjunction with, such procedure, which CHC considers to be Experimental/Investigational.

Preauthorization is required. Cost sharing and limitation depend on type and site of service.

Prior authorization required for temporomandibular joint surgery.

Prior authorization is required.