Limit: 3000.0 Dollars per Year

Exclusions: No coverage for injuries or damage to teeth, natural or otherwise, as a result of or caused by chewing food or similar substances.

Care must start within 3 months and be completed within 12 months of the injury.

Up to four years of intensive-level services that commence after you are two years of age and before you are nine years of age.

Intravenous chemotherapy is covered.

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

Coverage limited to children under age 5 or individuals with a chronic disability or medical condition that requires hospitalization or general anesthesia for dental care.

Limit: 1.0 Item(s) per 3 Years

Exclusions: No coverage for rental fees greater than the purchase price, continuous passive motion (CPM) devices, mechanical stretching devices, home spinal traction devices or standers, home INR (international normalized ration blood test) monitors, home phototherapy for dermatological conditions, cold therapy, cryotherapy, home automated external defibrillator (AED), DME with special features that are not medically necessary, DME for your comfort, personal hygiene, or convenience, self-help devices not medical in nature, Routine periodic maintenance, replacement of DME unless medically necessary, replacement of over-the-counter batteries, repairs due to abuse or misuse, light boxes designed for Seasonal Affective Disorder, devices and computers to assist in communication and speech except for speech aid devices and tracheo-esophageal voice devices, blood pressure cuffs and monitors, enuresis alarms, trusses, ultrasonic nebulizers, oral appliances for snoring.

Coverage is limited to a single purchase of a type of DME every 3 years. Coverage is limited to one of the following: a manual wheelchair, a motorized wheelchair, a knee walker, or a motorized scooter. Coverage is limited to one insulin infusion pump per year.

Services provided by a non-participating provider will be paid at the participating provider level.

Services provided by a non-participating provider will be paid at the participating provider level.

Limit: 1.0 Item(s) per Year

Exclusions: No coverage for services provided by a non-participating provider. Contact lenses covered in lieu of all other frames and/or lenses.

Coverage is limited to one pair of eyeglasses (frames and lenses) per year.

Limit: 30.0 Item(s) per Month

See brochure for a listing of free preventive drugs.

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for biofeedback.

No coverage for biofeedback.

Limit: 1.0 Item(s) per 3 Years

Exclusions: No coverage for batteries and cords; or hearing protection equipment.

Coverage is limited to one hearing aid per ear every three years. Coverage is limited to a single purchase (including repair/replacement) every three years for adults.

Limit: 60.0 Visit(s) per Year

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

MH/SUD office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance.

Limit: 30.0 Item(s) per Month

Exclusions: No coverage for weight loss programs.

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for vocational or industrial rehabilitation including work hardening programs; cardiac rehabilitation beyond Phase II; sports hardening and rehabilitation; services by a personal trainer; long-term or maintenance therapy.

Coverage is limited to 20 visits per year for pulmonary rehabilitation; 36 visits per year for cardiac rehabilitation; 30 visits per year for post-cochlear implant aural therpy; 20 visits for cognitive rehabilitation therapy. 20 visit limit for PT, OT and ST.

Limit: 30.0 Item(s) per Month

Exclusions: No coverage for services provided by a non-participating provider.

MH/SUD office visits are considered the same benefits as a primary care physician.

Limit: 1.0 Item(s) per 3 Years

Coverage limited to a single purchase of a type of prosthetic device every three years.

Exclusions: No coverage for reduction mammoplasty.

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for therapy for attention deficit disorder, hyperactivity disorder, sensory defensiveness, mental retardation, and related conditions; biofeedback; long-term and maintenance therapy.

Coverage is limited to 20 visits per year for physical thearpy and 20 visits per year for occupational thearpy.

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for long-term and maintenance thearpy.

Coverage is limited to 20 visits per year.

Exclusions: Coverage is limited to children through the last day of the calendar month of their 19th birthday; no coverage for services by a non-participating provider."

Coverage limited to services which are associated with a medical diagnosis of diabetes, peripheral vascular disease, or peripheral neuropathy.

Limit: 30.0 Days per Stay

Coverage limited to 30 days per confinement.

Limit: 30.0 Item(s) per Month

MH/SUD office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance.

Exclusions: No coverage for transplants that are not listed as approved transplant services; expenses related to purchase of any organ;services provided by a non-participating provider.

Exclusions: No coverage for cosmetic or elective orthodontic care, periodontal care, or general dental care.

Services provided by a non-participating provider will be paid at the participating provider level if for emergency medical care.

Exclusions: No coverage for services provided by a non-participating provider.