Limit: 30.0 Visit(s) per Year

Covered No Limit. Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Limit: 1.0 Item(s) per Year

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

Limit: 30.0 Visit(s) per Year

Combined limits for rehab and hab apply to Speech (30 visits), Occupational and Physical therapy (30 visits for OT and PT combined).

Limit: 2.0 Item(s) per 3 Years

Limit: 100.0 Visit(s) per Year

Exclusions: Respite Care is not a covered benefit.

Prior authorization may be required.

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

Limit: 30.0 Visit(s) per Year

Combined visits for rehab and hab: 30 visits combined for OT and PT; 30 visits for ST.

Limit: 240.0 Hours per Year

Prior authorization may be required. Limited to 240 hours or 30 days per year. (Based on an 8 hour shift/calendar year).

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality. 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria.

Limit: 30.0 Visit(s) per Year

Limit: 30.0 Visit(s) per Year

Limit: 1.0 Exam(s) per Year

Limit: 120.0 Days per Admission

Prior authorization may be required. Limited to 120 days per admission in a facility. Benefits renew after 180 days without care.

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Except for kidney and bone marrow/stem cell transplants, the maximum benefit for organ harvesting and procurement is $10,000 for each cadaveric organ and up to $45,000 for each organ procured from a living donor (including harvesting). Maximums are subject to copayments, deductibles and coinsurance, if any. If there are no Center of Excellence facilities for kidney transplants, living donor costs are limited to $50,000 (not including harvesting).