Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 36.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card.

Limit: 30.0 Visit(s) per Year

Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Limit: 1.0 Item(s) per Year

Covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eyeglasses.

Limit: 1.0 Item(s) per Year

OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-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. Refer to the prescription drug list for more information.

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient habilitation services; limited to 180 visits per year for developmental services. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 2.0 Item(s) per 3 Years

Prior authorization may be required - please contact the number listed on your ID card.

Limit: 50.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required. Coverage includes testing to diagnose infertility, infertility counseling and planning services; also, in vitro fertilization procedures are covered.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services.

When provided in conjunction with Diabetic Self-Management Training, for services needed by Members in connection with cleft palate management and for nutritional assessment programs provided in and by a Hospital. Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Prior authorization may be required - please contact the number listed on your ID card.

Covered in accordance with ACA guidelines.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

Limit: 30.0 Visit(s) per Year

60 inpatient days/year. Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 1.0 Exam(s) per Year

OON exam: Up to $38.50. Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eyeglasses. OON eyewear benefit: covered up to $50 for frames, lenses up to $37.50 and contact lenses up to $91.

Limit: 1.0 Exam(s) per Year

Up to $38.50 OON

Limit: 60.0 Days per Year

Prior authorization may be required - please contact the number listed on you ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.

Prior authorization may be required - please contact the number listed on your ID card.