Limited to treatment for accidental injury to natural teeth within 12 months of the accidental injury. Anesthesia and hospital charges for dental care, for a member less than 19 years of age or a member who is physically or mentally disabled, are covered if the member requires dental treatment to be given in a hospital or outpatient ambulatory surgical facility. The indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, should be used to determine whether performing dental procedures is necessary to treat the member?s condition under general anesthesia. This coverage does not apply to treatment for TMJ.

Limit: 12.0 Visit(s) per Year

Includes Osteopathic/Manipulation Therapy.

The per day inpatient copayment will apply for a maximum of four (4) days.

Including nutritional therapy.

Benefit depends on place of treatment.

Maximum of 1 wig per Insured Person, per year.

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

Children up to age 19, through the end of their birth month. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses for Children - One pair or one box per eye of contact lenses, including professional services ? in lieu of lenses and frame benefit, (may not receive contact lenses and frames 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 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.

Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Rehabilitative Services do not reduce maximums for Habilitative Services.

Limit: 100.0 Visit(s) per Year

Maximum does not include home infusion therapy or private duty nursing rendered in the home.

Respite Care: In-patient included.

The per day inpatient copayment will apply for a maximum of four (4) days.

Refer to the policy for more information regarding Diabetes.

The per day inpatient copayment will apply for a maximum of four (4) days.

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 Designated 90 day Retail Pharmacy.

Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for Rehabilitation Services. Cardiac Rehabilitation limited to 36 visits per year. Pulmonary Rehabilitation limited to 20 visits per year.

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

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

Limit: 82.0 Visit(s) per Year

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

Children up to age 19, through the end of their birth month.

Limit: 90.0 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 Designated 90 day Retail Pharmacy.

The per day inpatient copayment will apply for a maximum of four (4) days.

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.

You pay a copayment for each 30 day supply. Up to a 30-day supply at any participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy

Lifesource Travel maximum of $10,000 per transplant. Includes coverage for unrelated donor search services up to $30,000 per transplant; prior authorization required. See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility.

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