Gold Value 1819 + Adult Dental + Adult Vision ($1,300 Tier 1 Medical Deductible, High Value Network Savings, Open Access) - 36194FL0470003 Health Insurance Plan

Coverage is limited to care and stabilization treatment rendered within 62 calendar days of an accidental dental injury.

Includes general anesthesia and hospitalization services in connection with dental treatment provided in a hospital or ambulatory surgical center.

Limit: 1000.0 Dollars per Year

Calendar year maximum applies per individual and is combined between Routine Dental Services (Adult), Basic Dental Care ? Adult, and Major Dental Care ? Adult.

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

Limit: 36.0 Days per Lifetime

Limit: 26.0 Visit(s) per Year

Limit: 1.0 Visit(s) per 6 Months

Covered up through the end of the birth month in which the covered person reaches age nineteen (19). Basic and major dental care and orthodontic services.

In order to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of a certified diabetes educator or board certified physician specializing in endocrinology.

Exclusions: Items that are primarily for convenience or comfort and items available over-the-counter are excluded. The replacement of equipment is also excluded, unless it is non-functional and not practically repairable.

Limit: 130.0 Dollars per Year

Allowance may be used each calendar year to purchase standard eyeglass frames and lenses, or standard contact lenses, in lieu of eyeglasses.

Limit: 1.0 Item(s) per Year

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

Preferred Generic Drugs: $3 copay for 30 days' supply.

BRCA Analysis to determine a woman's genetic risk for breast and ovarian cancer is covered as a preventive benefit when medical necessity criteria are met and authorized in advance by the health plan.

Limit: 35.0 Visit(s) per Year

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. Combined limit for all outpatient habilitative physical, occupational and speech therapy. Limit applies per condition.

Limit: 60.0 Visit(s) per Year

One date of service is equal to one visit.

Exclusions: Covered hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling or custodial care.

Cost-share applies per visit, per type

Includes chemotherapy, infusions, therapeutic injections, allergy immunotherapy, and other medications ordered and administered by a provider.

Coverage for inpatient rehabilitation services are limited to 21 days per calendar year.

Limit: 1000.0 Dollars per Year

Calendar year maximum applies per individual and is combined between Routine Dental Services (Adult), Basic Dental Care ? Adult, and Major Dental Care ? Adult.

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

The cost-share that displays applies to Mental/Behavioral Health Outpatient Services only. For Mental Health Office Visit, the Mental Health Office Visit cost-share applies. Please refer to the plan policy documents for detailed information.

Virtual Health provided as a means to receive this benefit.

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

Treatment provided at a primary care physician's office will be subject to the Primary Care Visit cost-share.

Specialist Visit cost-share will apply if visit is in a specialist's office.

Limit: 35.0 Visit(s) per Year

Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.

A structured program of active treatment for psychiatric care that is more intense than the care performed in a physician?s or therapist?s office.

Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share. Birthing classes are covered at $0 copay.

Limited to services recommended with an "A" or "B" rating by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended for routine use by the Centers for Disease Control and Prevention (CDC), and services listed in guidelines of the Health Resources and Services Administration (HRSA) for women and children.

Virtual Health provided as a means to receive this benefit.

Covered prosthetic devices (except cardiac pacemakers and prosthetic devices incident to a mastectomy) are limited to the first such permanent prosthesis, including the first temporary prosthesis if necessary, prescribed for each condition. Coverage is provided for necessary replacement of a prosthetic device owned by the enrollee when due to irreparable damage, wear, a change in the enrollee's condition, or when necessitated due to growth of a child.

Any cosmetic reconstructive surgery is excluded. Surgery performed outpatient is subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share.

Limit: 35.0 Visit(s) per Year

Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.

Limit: 35.0 Visit(s) per Year

Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.

Limit: 1000.0 Dollars per Year

Calendar year maximum applies per individual and is combined between Routine Dental Services (Adult), Basic Dental Care ? Adult, and Major Dental Care ? Adult.

Limit: 1.0 Exam(s) per Year

Includes one routine adult eye exam every calendar year with dilation as necessary.

Limit: 1.0 Exam(s) per Year

Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

Routine foot care, including any service or supply in connection with foot care, is only covered when medically necessary.

Limit: 60.0 Days per Year

Virtual Health provided as a means to receive this benefit.

Coverage is limited to 30-day supply from preferred specialty pharmacy.

Virtual Health provided as a means to receive this benefit.

Includes bone marrow transplant

Limit: 1.0 Item(s) per 6 Months

One splint in a six (6) month period is covered, unless a more frequent replacement is determined to be medically necessary. Splints are subject to the Durable Medical Equipment cost-share. Medically necessary outpatient surgical procedures are subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share.

Virtual Health provided as a means to receive this benefit. Virtual Urgent Care copay $15.

Cost-share applies per visit, per type