Pediatric only - Restorations of the mouth, tooth, or jaw which are necessary due to an accidental injury are limited to those services, supplies, and appliances appropriate for dental needs. These are not pediatric only benefits. The section refers to some excluded services that are covered under Pediatric Dental but this section applies to all enrollees under the product.

Pre-certification is required. Surgery for obesity will be a Covered Service only when required due to morbid obesity. The participant meets the current NIH (National Institutes of Health) surgical criteria.

Limit: 15.0 Visit(s) per Year

Limited to 15 visits per calendar year.

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

Limit: 1.0 Visit(s) per 6 Months

Limited to one every six months.

Covered Outpatient self-management training and education are limited to a one-time evaluation and training program when Medically Necessary, within one (1) year of diagnosis.

Some items require Pre-Certification. The rental or the purchase of durable medical equipment, whichever is less expensive, is a Covered Service. When a purchase is authorized, Benefits will also be provided for repair, maintenance, replacement, and adjustment of the equipment.

Limit: 1.0 Item(s) per Year

Covers one pair of eyeglasses or 12 month supply of contacts per calendar year.

Covered when medically necessary.

Limit: 30.0 Days per Month

Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

Limit: 20.0 Visit(s) per Year

Outpatient Habilitative Benefits are limited to a maximum of twenty (20) visits per calendar year per Participant.

Pre-Certification is required. The need for Home Healthcare must be directly related to the Condition for which the Participant's hospitalization was required.

Cost share applies to office visits, please see SBC for Mental Health Outpatient Services.

Limit: 30.0 Days per Month

Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

Coverage is for medically necessary orthodontia only.

Limit: 60.0 Visit(s) per Year

Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.

Limit: 30.0 Days per Month

Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

Cost sharing for Virtual Primary Care matches in-person office visit.

Inpatient Private Duty Nursing Services are Covered Services only in certain circumstances such as: The Participant's Condition would ordinarily require that the Participant be placed in an intensive or coronary care unit, but the Hospital does not have such facilities.

Some items require Pre-Certification.

Reconstructive procedures are covered when the primary purpose of the procedure is either treatment of a medical condition or required to improve or restore physiologic function.

Limit: 60.0 Visit(s) per Year

Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.

Limit: 20.0 Visit(s) per Year

Outpatient is limited to 40 visits per calendar year for physical therapy and combined 20 visit per calendar year maximum for occupational therapy & speech therapy.

Limit: 1.0 Exam(s) per Year

Covers one exam per calendar year.

Covered as medically necessary for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease

Pre-Certification Required and subject to approval by Case Benefit Management. Care must begin within 14 days after discharge from the hospital or skilled nursing facility. Inpatient Rehabilitation Facility services limited to 45 days per year.

No referral needed for a specialist.

Limit: 30.0 Days per Month

Specialty medications are limited to a 1-month supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

Pre-Admission Review is required prior to obtaining non-maternity and non-emergency Inpatient Human Organ Transplant services.

$0 Virtual Urgent Care visits are available through vendor. See SBC for additional cost share details for in-person urgent care visits.