Pediatric only - Restorations of the mouth, tooth, or jaw which are necessary due to an accidental injury are limited to those services, supplies, and appliances appropriate for dental needs. These are not pediatric only benefits. The section refers to some excluded services that are covered under Pediatric Dental but this section applies to all enrollees under the product.

Limit: 1.0 Procedure(s) per Lifetime

Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria.

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per calendar year.

Limit: 1.0 Item(s) per Lifetime

Covered Outpatient self-management training and education are limited to a one-time evaluation and training program when Medically Necessary, within one (1) year of diagnosis.

Some items require Pre-Certification. The rental or the purchase of durable medical equipment, whichever is less expensive, is a Covered Service. When a purchase is authorized, Benefits will also be provided for repair, maintenance, replacement, and adjustment of the equipment.

Limit: 1.0 Item(s) per Year

Covers one pair of eyeglasses or 12 month supply of contacts per calendar year.

Limit: 20.0 Visit(s) per Year

Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.

Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant's hospitalization was required.

Pre-Certification is required. The Participant must be diagnosed with a terminal illness for which the attending Physician's prognosis for life expectancy is estimated to be six (6) months or less.

Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.

Pre-admission Review before being admitted as an Inpatient to a Hospital for non-maternity or non-emergency Conditions.

The cost sharing that displays applies to out-patient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Limit: 20.0 Visit(s) per Year

Outpatient Rehabilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.

Inpatient Private Duty Nursing Services are Covered Services only in certain circumstances such as: The Participant's Condition would ordinarily require that the Participant be placed in an intensive or coronary care unit, but the Hospital does not have such facilities.

Some items require Pre-Certification.

Pre-Certification Required. Reconstructive procedures which correct deformities of the jaw. Reconstructive Surgery is a Covered Service only where Participant's Surgery is required as the result of a birth defect, accidental injury, or a malignant disease process or its treatment.

Limit: 60.0 Visit(s) per Year

Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.

Limit: 20.0 Visit(s) per Year

Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.

Limit: 1.0 Exam(s) per Year

Covers one exam per calendar year subject to deductible and coinsurance.

Pre-Certification Required and subject to approval by Case Benefit Management. Care must begin within 14 days after discharge from the hospital or skilled nursing facility.

No referral needed for a specialist.

Must be pre-approved.

The cost sharing that displays applies to out-patient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services.