For treatment within 12 months of the date of injury to restore teeth to a functional state.

Limit: 12.0 Visit(s) per Year

Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided. Acupuncture services must be prior authorized as medically necessary.

Other medically necessary diagnostic services provided in a hospital or outpatient setting, including testing or observation to diagnose the extent of a medical condition.

Limit: 20.0 Visit(s) per Year

Plan uses the term "spinal manipulation." Other services such as lab and diagnostic x-rays are under the Plan?s standard benefit for the type of service provided. Spinal manipulation services must be prior authorized as medically necessary.

Benefit is limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery.

Limit: 3.0 Hours per Year

Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis.

See policy for limitations.

Limit: 1.0 Item(s) per Year

Lenses and frames covered once per year for members through the end of the month in which they reach age 19. Contact lenses covered in lieu of eyeglasses.

See policy for information about gender affirming care.

Up to 30-day supply (retail) and 90-day supply (mail order) per prescription. Insulin member cost share maximum of $85 for a 30-day supply. Select tier includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.

Limit: 30.0 Visit(s) per Year

Visit limits do not apply to mental/behavioral health/substance use disorder.

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear if prescribed, fitted, and dispensed by a licensed audiologist with the approval of a licensed physician. Coverage will be provided every 36 months as medically necessary for the treatment of a member's hearing loss.

Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.

Some medications may be limited to certain providers or settings.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Up to 30-day supply (retail) and 90-day supply (mail order) per prescription. Insulin member cost share maximum of $85 for a 30-day supply. Non-preferred brand medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.

Authorization required after first 5 visits.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Limit: 30.0 Visit(s) per Year

Additional 30 visits for neurological conditions. Visit limits do not apply to mental/behavioral health/substance use disorder.

Up to 30-day supply (retail) and 90-day supply (mail order) per prescription. Insulin member cost share maximum of $85 for a 30-day supply. Preferred medications are clinically effective at a favorable cost. Generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications may be included in this tier. If using a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and brand medication.

7 exams age 1-4 and one per year age 5+. See policy for other visit limits.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Limited to one attempt at cosmetic or reconstructive surgery when necessary to correct a functional disorder; or when necessary because of an accidental injury, or to correct a scar or defect that resulted from treatment of an accidental injury; or when necessary to correct a scar or defect on the head or neck that resulted from a covered surgery.

Limit: 30.0 Visit(s) per Year

Additional 30 visits for neurological conditions. Visit limits do not apply to mental/behavioral health/substance use disorder.

Limit: 30.0 Visit(s) per Year

Additional 30 visits for neurological conditions. Visit limits do not apply to mental/behavioral health/substance use disorder.

Limit: 1.0 Exam(s) per Year

Once per year for members through the end of the month in which they reach age 19.

Benefit is limited to persons with a medical condition that requires it.

Limit: 60.0 Days per Year

Routine nursing and custodial care are not covered.

Includes office visits by naturopaths.

Up to 30-day supply per prescription at preferred specialty pharmacies only. Specialty medications often require special handling techniques, careful administration and a unique ordering process. Moda Health provides enhanced member services for these medications. If a member does not purchase these medications at the exclusive specialty pharmacy, the expense will not be covered.

$5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.

Center of excellence only. $7,500 maximum for travel and housing per transplant.

1 in-hospital newborn visit and 6 additional visits for the first year of life.