Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

1. The patient must have a body-mass index (BMI) greather than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components:a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. The member must be 18 years or older, or have reached full expected skeletal growth.

Limit: 20.0 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.

Limit: 1.0 Item(s) per Benefit Period

Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary.

Limit: 42.0 Visit(s) per Year

1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.

The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.

Limit: 60.0 Visit(s) per Year

Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined. This visit limit does not apply to services for treatment of autism spectrum disorder.

Prescription insulin will not exceed $25 per prescription unit

Limit: 1.0 Exam(s) per Year

Benefits are limited to one preventive physical exam per calendar year, unless additional visits are necessary to obtain all covered preventive health care.

Virtual visits are unlimited with a $0 copayment when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses.

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST). This visit limit does not apply to services for treatment of autism spectrum disorder.

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST). This visit limit does not apply to services for treatment of autism spectrum disorder.

Limit: 90.0 Days per Year

There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s).

Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.