Limit: 20.0 Visit(s) per Year

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

Up to age 19. One pair of glasses (lenses and frames from the pediatric selection) per year. May receive one pair of contact lenses, including professional services, in lieu of lenses and frame benefit. May not receive contact lenses and frames/lenses in same benefit year.

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 any Designated 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.

Physical Therapy limited to 20 visits per year; Occupational Therapy limited to 20 visits per year; Speech Therapy limited to 20 visits per year.

Hearing Aid Devices - 1 Hearing Aid per ear, every 3 years. Hearing Aid Exam/Evaluation - Only services necessary to select, fit and adjust the hearing aid are included in this benefit. Bone Anchored Hearing Aids - Not Covered

Limit: 60.0 Visit(s) per Year

Refer to the policy for more information regarding Diabetes.

This benefit applies to Mental Health Office Visits. All other Mental Health Outpatient Services are covered at the Outpatient professional services benefit. Please refer 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 Designated 90 day Retail Pharmacy. After deductible, you pay a copayment for each 30 day supply.

Unlimited visits limited to Nutritional Counseling associated with Home Health and Diabetes Management. Services associated with Preventive Care are covered at the Preventive Care benefit level and treatment described in connection with a mental health or substance abuse diagnosis are covered at the Outpatient Mental Health benefit level

Physical Therapy limited to 20 visits per year; Occupational Therapy limited to 20 visits per year; Speech Therapy limited to 20 visits per year.

Up to a 30 day supply at any Participating Pharmacy, or up to a 90 day supply at any Designated 90 day retail pharmacy. After deductible, 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.

Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services.

Limited to 20 visits per year for Occupational therapy and 20 visits per year for Physical therapy; same visits and coverage apply to habilitative services.

Limit: 20.0 Visit(s) per Year

Same limits and coverage apply for habilitative services.

Limit: 1.0 Visit(s) per Year

Up to age 19.

Limit: 60.0 Days per Year

Including other high cost drugs. Up to a 30-day supply at any Participating Pharmacy or up to a 30-day supply at a Designated 90 day Retail Pharmacy. After deductible, you pay a copayment for each 30 day supply.

This benefit applies to Mental Health Office Visits. All other Mental Health Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

Lifesource Transplant Network travel benefit maximum of $10,000 per insured person per transplant. See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility.