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 conventional or one box of disposable lenses per eye, 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 a Designated 90-day Pharmacy. Refer to the prescription drug list for more information.

Coverage of physical, occupational, and speech therapy is limited to 20 visits annual max per therapy.

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

This benefit applies to Mental Health Office Visits. All other 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 Pharmacy. Refer to the prescription drug list for more information.

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. .

Coverage of physical, occupational, and speech therapy is limited to 20 visits annual max per therapy.

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

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 Exam(s) per Year

Up to age 19.

Limit: 60.0 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 Pharmacy. Refer to the prescription drug list for more information.

This benefit applies to Substance Abuse Disorder Office Visits. All other Outpatient Services are covered at the Outpatient professional services benefit. Please refer 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 Retail Pharmacy. Refer to the prescription drug list for more information.

Lifesource Transplant Network travel benefit maximum of $10,000 per insured person per transplant. Coverage for travel expenses not available for services outside of the Lifesource Transplant Network. 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.