An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

Limit: 20.0 Visit(s) per Year

Must be medically necessary. A treatment plan outlining goals of therapy, mode of therapy and duration of therapy must be submitted to Company by the provider prior to the initiation of treatment. The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy.

Minimum stay of 48 hours; no charge for professional services

Limit: 2.0 Visit(s) per Year

Various limitations apply

The ER Copay is waived if the visit results in an inpatient admission.

Air ambulance services are covered in only specified situations.

Limit: 1.0 Item(s) per Benefit Period

Quantity limits, authorizations and step therapy limits may apply.

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

May be available through the Care Management Program when provided by a network provider and prior authorization is received.

Limit: 6.0 Months per Lifetime

Subject to Care Management.

Copays, if applicable, are per day for first three days only.

Lab services in the Emergency Room are subject to the deductible, if applicable.

An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

Inpatient treatment for mental/behavioral health disorders must be Authorized

Quantity limits, authorizations and step therapy limits may apply.

Limit: 4.0 Visit(s) per Year

Coverage only for diabetes education.

Medically Necessary orthodontia only.

Quantitative limits depend on the type of visit.

Limit: 36.0 Visit(s) per Year

Benefits available for outpatient cardiac rehabilitation.

Quantity limits, authorizations and step therapy limits may apply.

Covered services must be included in Grade A and B Recommendations of the USPSTF and include all other preventive health services required by PPACA.

Various limitations apply as stated in the Benchmark plan.

Must be medically necessary. Company may require a treatment plan, outlining the goals of therapy, mode of therapy, and duration of therapy, to be submitted by the provider prior to the initiation of treatment.

Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy.

Limit: 20.0 Visit(s) per Year

The 20 visit limit is combined for chiropractic services, occupational therapy, and physical therapy.

Limit: 20.0 Visit(s) per Year

Not covered for learning disabilities and development problems.

Limit: 2.0 Visit(s) per Year

Covers exam and cleaning

Limit: 1.0 Visit(s) per Year

An added benefit

Limit: 1.0 Visit(s) per Year

Limit: 1.0 Visit(s) per Year

Requires a Diabetes diagnosis.

Limit: 30.0 Days per Benefit Period

Three-day prior inpatient stay

Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply.

Inpatient treatment for substance abuse must be Authorized

Non-EHB and out-of-network transplant services not covered

Medical necessity documentation and a treatment plan must be submitted to and approved by the Company prior to the commencement of treatment. Prior authorization is required.

Exclusions: Non-Vantage Weight Loss programs are excluded.

Vantage Weight Loss programs are covered as part of the Vantage Wellness Program.