Limit: 3000.0 Dollars per Episode

Limited to $3,000 per occurrence.

Limit: 12.0 Visit(s) per Year

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

Limit: 1.0 Item(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits.

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-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.

No limit applies to outpatient habilitation services. Inpatient habilitation services are limited to 60 Days per year.

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

Limit: 100.0 Visit(s) per Year

Limited to 14 days per lifetime for respite care covered in conjunction with hospice services.

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

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

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

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

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

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.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Limit: 116.0 Visit(s) per Year

Per year, outpatient cardiac therapy is limited to 36 visits, outpatient pulmonary therapy is limited to 20 visits, outpatient speech, occupational and physical therapy are limited to 20 visits each. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration.

Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs.

Limit: 90.0 Visit(s) per Year

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: 40.0 Visit(s) per Year

20 visits per year each for outpatient physical & occupational therapy. Inpatient rehabilitation limited to 60 Days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 20.0 Visit(s) per Year

20 visits per year for outpatient speech therapy. Inpatient rehabilitation limited to 60 Days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 1.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision High Option plan, including low vision benefits.

Limit: 90.0 Days per Year

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.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

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

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

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.

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.