Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 20.0 Visit(s) per Year

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 Benefit Period

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: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy.

Limit: 2.0 Item(s) per 3 Years

Limited to 1 item per ear every 3 years.

Limit: 60.0 Visit(s) per Year

Respite care covered in conjunction with hospice services.

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

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

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

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.

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: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Covered in accordance with ACA guidelines.

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

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy and speech therapy); Limited to 36 visits per year per therapy for cardiac and pulmonary therapy. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 1.0 Exam(s) per Year

Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses.

Limit: 1.0 Exam(s) per Year

Limit: 60.0 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. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

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

Covered in accordance with ACA guidelines.