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

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: 35.0 Visit(s) per Year

Chiropractic care also known as "spinal manipulation" in the handbook. Combined limit of 35 visits for rehabilitation, habilitation and spinal manipulation.

Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.

Limits apply to some durable medical equipment.

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 the handbook for information about gender affirming care.

Up to 30 days per prescription for retail and up to 90 days for mail order. One copay for a 30-day supply. Insulin member cost share maximum of $25 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: 35.0 Visit(s) per Year

Up to a limit of 35 visits per year. The limit does not apply to mental health and substance use disorder.

Limit: 1.0 Item(s) per 3 Years

To restore or correction of impaired speech or hearing loss.

Limit: 60.0 Visit(s) per Year

Preauthorization is required.

Some medications may be limited to preferred medication suppliers

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.

Preauthorization is required.

Preauthorization is required.

Up to 30 days per prescription for retail and up to 90 days for mail order. One copay for a 30-day supply. Insulin member cost share maximum of $25 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.

For some medical conditions

Limit: 35.0 Visit(s) per Year

Outpatient rehabilitation services have a combined limit of 35 visits per year for rehabilitation and spinal manipulation. The limit does not apply to mental health and substance use disorder.

Up to 30 days per prescription for retail and up to 90 days for mail order. One copay for a 30-day supply. Insulin member cost share maximum of $25 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 the handbook for other visit limits.

Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed.

Limit: 1.0 Exam(s) per Year

Limit: 1.0 Visit(s) per Year

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

When required for medical conditions

Limit: 25.0 Visit(s) per Year

Up to 30 days per prescription. Insulin member cost share maximum of $25 for a 30-day supply. 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.

Preauthorization is required.

Certain services require preauthorization.

Priot authorization is required. Must use an authorized transplant facility.

Excludes any non-surgical or non-diagnostic services or supplies

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