Limit: 12.0 Visit(s) per Year

Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.

Limit: 10.0 Visit(s) per Benefit Period

Exclusions: Massage or massage therapy, even as part of a physical therapy program. Homeopathic medicines or homeopathic supplies.

Limit: 1.0 Procedure(s) per Episode

Exclusions: Cosmetic surgery (except in certain situations). See policy for more information.

Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary. See policy for more information.

Exclusions: The benefit does not cover further treatment provided on referral from the emergency room.

For emergency medical conditions, out-of-network providers are paid at the in-network provider level. Out-of-network providers may bill members for charges in excess of the maximum plan allowance.

Limit: 1.0 Item(s) per Benefit Period

Regardless of whether eye glasses are purchased through an in-network or out-of-network provider the first $150 is covered. The remaining cost is subject to plan deductible and coinsurance.

Procedures, services, or supplies related to gender affirmation are not covered unless medically necessary.

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

See policy for more information.

The diagnosis and treatment of hearing loss and one amplification device for each ear every three years as required be an audiologist for members age 18 and younger.

Limit: 180.0 Visit(s) per Benefit Period

Exclusions: Private duty nursing not covered

Covered services include services by licensed Home Health Agency providing skilled nursing; physical, occupational, and speech therapy; and medical social work services.

Exclusions: Services and supplies for in vitro fertilization, erectile dysfunction, sexual dysfunction, or surgery to reverse voluntary sterilization. Services provided by out-of-network providers are not covered.

Treatment includes services to diagnose infertility, services related to artificial insemination.

Exclusions: Charges for inpatient stays that began before you were covered by this plan.

Charges for a hospital room are covered up to the hospital's semi-private room rate (or private room rate, if the hospital does not offer semi-private rooms). Charges for a private room are covered if the attending physician orders hospitalization in an intensive care unit, coronary care unit, or private room for medically necessary isolation.

This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008.

This health plan complies with all federal laws an regulations related to the Mental Health Parity and Addiction Equity Act of 2008.

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

See policy for more information.

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.

Exclusions: Missed appointments and get acquainted visits. See policy for more information.

Exclusions: Private duty nurse not covered.

Limit: 1.0 Visit(s) per Benefit Period

Exclusions: Orthoptics, vision therapy, or other services to correct refractive error.

When using an in-network provider eye exams are covered in full. When using an out-of-network provider the first $40 is covered and the remaining cost is member responsibility.

Limit: 60.0 Days per Benefit Period

Exclusions: Confinement or custodial care is not covered. See policy for more information.

Exclusions: Missed appointments and get acquainted visits. See policy for more information.

Certain drugs may fall under a higher or lower cost sharing amount than is listed here. See policy for more information.