Limit: 12.0 Visit(s) per Year

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Limit: 1.0 Item(s) per Year

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-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: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Limited to 60 days per year (includes day rehabilitation therapy services provided on an outpatient basis). Limits are combined both In and Out of Network.

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

Limit: 100.0 Visit(s) per Year

Respite Care is covered as part of hospice services only.

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Prior authorization may be required - please contact the number listed on your ID card.

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: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply. Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.

Covered in accordance with ACA guidelines.

Limit: 82.0 Visit(s) per Year

Must be provided as part of home health care or outpatient visit. Inpatient is not covered.

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; (c) chest wall reconstruction including aesthetic flat closure; and (d) 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. Prior Authorization may be required - please contact the number listed on your ID card.

Limit: 40.0 Visit(s) per Year

Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.

Limit: 20.0 Visit(s) per Year

Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.

Limit: 1.0 Visit(s) per Year

Limit: 90.0 Days per Year

Prior authorization may be required - please contact the number listed on your ID card.

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.

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

Covered in accordance with ACA guidelines.