Limit: 12.0 Visit(s) per Year

Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.

Limit: 4.0 Procedure(s) per Year

Limit: 12.0 Visit(s) per Year

Limit: 1.0 Visit(s) per 6 Months

Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit, covers both medical emergency transport and non-emergent transport.

Limit: 1.0 Item(s) per Year

Under age 19; 1 pair of frames and lenses PCY includes polycarbonate lenses and scratch resistant coating; 12 month supply of contacts in lieu of glasses; over age 19 Not Covered.

Limit: 90.0 Item(s) per Month

Up to 90 day supply Retail (copay times 3); 90 day supply for Mail Order. This tier contains only Preferred Generic Drugs.

Limit: 45.0 Visit(s) per Year

Habilitative services is only covered in the context of autism spectrum disorders services, including ABA, counseling and treatment programs necessary to develop, maintain, or restore the functioning of an individual.

Limit: 130.0 Visit(s) per Year

130 visits per applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a home health aide directly supervised by one of the above providers; and a person with a master's degree in social work.

Limit: 6.0 Months per Lifetime

Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member.

Limit: 1.0 Procedure(s) per 3 Years

The cost sharing that displays applies to outpatient office visits only. All other outpatient services (Outpatient Facility Fee, Laborartory Outpatient and Professional Services, etc.) may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Limit: 90.0 Item(s) per Month

Up to 90 day supply Retail (copay times 3); 90 day supply for Mail Order. This tier contains only non-preferred drugs.

Unlimited if Medically Necessary Only

Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician.

Limit: 45.0 Visit(s) per Year

A 'visit' is a session of treatment for each type of therapy. Each type of therapy combined accrues toward the above visit maximum. Multiple therapy sessions on the same day will be counted as 1 visit, unless provided by different health care providers.

Limit: 90.0 Item(s) per Month

Up to 90 day supply Retail (copay times 3); 90 day supply for Mail Order.

Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can't be repaired, or replacement is prescribed by a physician because of a change in your physical condition.

Breast reconstruction allowed.

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

Limit: 45.0 Visit(s) per Year

Visit limit for physical, speech, and occupational therapy services combined.

Limit: 2.0 Exam(s) per Year

Routine Exam - 2 PCY and Cleanings- 2 PCY; Routine X-rays (bitewing) - 1 PCY; Annual Maximum $750

Limit: 1.0 Exam(s) per Year

Under age 19, 1 PCY; Over age 19 Not Covered

Routine foot care when the member is a diabetic.

Limit: 60.0 Days per Year

Limit: 30.0 Item(s) per Month

30 day supply Retail and Mail

Limit: 75000.0 Dollars per Lifetime

Quantitative limit on Donor costs only. The types of solid organ transplants and bone marrow/stem cell reinfusion procedures that currently meet the plan's criteria for coverage are: Heart, Heart/double lung, single lung, Double lung, Liver, Kidney, Pancreas, Pancreas with kidney, Bone marrow (autologous and allogenic), Stem cell (autologous and allogeneic).