30 visit limit for Physical Therapy and Occupational Therapy combined (including chiropractic). PCP copay applies for Physical and Occupational Therapy visits and Chiropractic visits.

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

Children up to age 19. Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period.

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.

Combined 30 visit limit for occupational and physical therapies. Speech Therapy limited to 30 visits per year. PCP copay applies for Physical and Occupational Therapy visits and Chiropractic visits.

Limit: 1.0 Item(s) per 3 Years

Limited to one hearing aid, per hearing impaired ear, every 36 months.

Includes services related to the diagnosis, treatment and correction of conditions resulting in infertility. Excludes treatment of infertility such as in vitro fertilization and other types of artificial or surgical means of conception and associated procedures and the related medications are Not Covered.

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. You pay a copayment for each 30 day supply.

Limited to preventive services only, as part of the Preventive Care benefit.

Cardiac Rehabilitation limited to 30 visits per year; Pulmonary Rehabilitation limited to 1 course per year. Physical Therapy, Occupational Therapy, Chiropractic Care limited to 30 combined visits per year; Speech Therapy limited to 30 visits per year. PCP copay applies for Physical and Occupational Therapy visits and Chiropractic visits.

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.

Routine physicals and other preventive services.

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

Medically necessary care while receiving active care management, prior authorization required.

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

Limit: 30.0 Visit(s) per Year

Limit: 1.0 Visit(s) per Year

Children up to age 19. Limited to 1 visit per 12 month period.

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 90-day supply at a Designated 90 day Retail Pharmacy. You pay a copayment for each 30 day supply.

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

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.