Silver 5000 $20 Generic Drugs - 50328WV0010023 Health Insurance Plan

Surgery determined to be Medically Necessary is covered.

Limit: 30.0 Visit(s) per Benefit Period

Manipulation Therapy is limited to 30 visits. Physical Therapy is limited to 30 visits. Limits are combined with services delivered under Outpatient Rehab or Habilitation Services.

Limit: 20.0 Visit(s) per Episode

Physical Therapy, Occupational Therapy, Osteopathic Manipulation, a Chronic Pain Management Program, and Chiropractic Services limited to 20 combined visits per event. Separate limits from Rehabilitative and Habilitative services.

Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.

Ambulance transports must be made to the closest local facility that can provide you with covered services appropriate for your medical condition.

Limit: 1.0 Item(s) per Year

Limited to one pair of glasses or contact lenses per benefit year.

Surgery determined to be Medically Necessary is Covered

Limit: 30.0 Visit(s) per Benefit Period

Physical, Occupational, and Manipulation Therapy limited to 30 visits each.

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.

Must have a terminal illness with life expectancy of 6 months or less.

The diagnosis and treatment of underlying medical causes of infertility are generally covered, however infertility treatments, such as artificial insemination/invitro fertilization, are not covered.

The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share.?

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.

Diet education covered in the context of diabetes self-management education.

Limit: 30.0 Visit(s) per Benefit Period

Physical, Occupational, Manipulation, and Pulmonary Therapy limited to 30 visits each. Cardiac Rehabilitation limited to 36 visits. Pulmonary Therapy limited to 30 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply.

Limit: 35.0 Visit(s) per Benefit Period

A visit equals 8 hours or less.

(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 visit each for Occupational and Physical Therapies.

Limit: 1.0 Exam(s) per Year

The cost sharing that displays applies to office visits only. All other services are subject to the Outpatient Professional Services cost share.?

Quantitative limit units apply, see Summary of Benefits and Coverage.