Limit: 1.0 Procedure(s) per Lifetime

Exclusions: Excludes removal of excess skin from the abdomen, arms or thighs.

For surgical treatment of morbid obesity.

Benefit limitations may apply to individual services.

Limit: 30.0 Visit(s) per Year

Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.

Childbirth/delivery professional services follow inpatient physician/surgeon fees.

Limit: 1.0 Visit(s) per 6 Months

Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment.

Limit: 1.0 Item(s) per Year

Limit: 30.0 Days per Month

90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

Limit: 30.0 Visit(s) per Year

Exclusions: Group classes for pulmonary rehabilitation.

Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.

Limit: 60.0 Visit(s) per Year

Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household.

Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation.

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

Exclusions: Lab tests that are not ordered by Doctor of Other Provider.

Limit: 3.0 Treatment(s) per Lifetime

Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.

Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy.

Limit: 18.0 Visit(s) per Year

Limited to 18 Presumptive Drug Tests per year. Limited to 18 Definitive Drug Tests per year.

Benefit limitations may apply to individual services.

Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient.

Exclusions: Excludes marriage and family therapy.

Limit: 30.0 Days per Month

90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

Nutritional counseling visits are separate from the obesity-related office visits.

Coverage is for medically necessary orthodontia only.

Limit: 30.0 Visit(s) per Year

Exclusions: Applied Behavior Analysis (ABA) therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy.

Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.

Limit: 30.0 Days per Month

90-day supplies are available through retail pharmacies or home delivery.? Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

All preventive care that is not state mandated is not covered OON.

Cost sharing for Virtual Primary Care matches in-person office visit. See SBC for additional cost share details.

Exclusions: Excludes services provided by a close relative or a member of the household.

Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan.

Prosthetic appliance must replace all or part of a body part or its function.

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

Limit: 30.0 Visit(s) per Year

Limited to 30 visits for any combination of physical therapy, occupational therapy, and manipulative treatment including chiropractic care.

Limit: 30.0 Visit(s) per Year

Exclusions: Excludes speech therapy for stammering or stuttering.

Limit: 1.0 Visit(s) per Year

Limit: 60.0 Days per Benefit Period

Limit will be any combination of Skilled Nursing Facility or Inpatient Rehabilitation Facility Services.

Limit: 30.0 Days per Month

Covers outpatient self-administered prescription legend drugs from a participating network pharmacy. Quantity limits per prescription may apply.

Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient.

Exclusions: Excludes marriage and family therapy.

Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues.

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

Exclusions: Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions.

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.

$0 Virtual Urgent Care visits. See SBC for additional cost share details.