Surgery determined to be Medically Necessary is covered.

Oral Evaluations (Exams), Prophylaxis (cleanings), Fluoride Treatments, Sealants, Consultations

Limit: 30.0 Visit(s) per Benefit Period

30 visits per benefit period for other than chronic pain 20 visits per event for chronic pain (visit limits are combined for physical therapy, occupational therapy and spinal manipulations)

Limited to reconstruction to restore body function or malformation caused by disease, trauma, birth defects, growth defects, prior therapeutic processes or as a result of an act of family violence

Limit: 2.0 Visit(s) per Year

Limit: 1.0 Item(s) per Year

Limit: 30.0 Visit(s) per Benefit Period

Limit does not apply to Habilitative services for the treatment of a Mental Health or Substance Abuse diagnosis.

Limit: 100.0 Visit(s) per Benefit Period

The following are Covered Services when you are Homebound and receive them from a Hospital or a Home Health Care Agency: Intermittent Skilled Care rendered by a registered or licensed practical nurse or nurse-midwife; Physical therapy, occupational therapy or speech therapy; Medical and surgical supplies; Prescription Drugs; Oxygen and its administration; Medical social Services; Home health aide visits when you are also receiving Skilled Care or Therapy Services; Laboratory tests; Home infusion therapy.

Life expectancy 6 months or less

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder.

Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group?s prescription drug program

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder.

Radiographs (all x-rays), space maintainers, amalgam restorations (metal filings), resin based composite filings (white fillings), crowns, inlays, onlays, crown repair, endodontic therapy (root canals, etc.), other endodontic services, surgical periodontics, non-surgical periodontics, periodontal maintenance, prosthetics (complete or fixed partial dentures), adjustments and repair of prosthetics, other prosthetic services, implant services, simple extractions, surgical extractions, oral surgery, general anesthesia, nitrous oxide and/or IV sedation

Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.'

Medically Necessary Orthodontics, with prior approval and written plan of care

Limit: 35.0 Visit(s) per Benefit Period

(a) only those that restore a body function or which were caused by disease, trauma, birth defects, growth defects, prior therapeutic processes; or (b) reconstructive Surgery following Covered Services for a mastectomy, including reconstruction of the other breast for the purpose of restoring symmetry; or (c) reconstructive or cosmetic Surgery necessary as a result of an act of family violence.

Limit: 30.0 Visit(s) per Benefit Period

30 Rehab and 30 Habilitative/benefit period for other than chronic pain. Limit: 20 Rehab and 20 Habilitative/event for chronic pain (limits combined for PT, OT and spinal manipulations). Limit does not apply to therapy services for mental health or substance use disorder.

Limit: 1.0 Exam(s) per Year

Orthotics, splints and appliances are limited to one every 3 years

The copayment, if any, does not apply to urgent care services prescribed for the treatment of mental illness or substance use disorder.

Copayments, if any, do not apply to diagnostic services prescribed for the treatment of mental illness or substance use disorder.