Limit: 1000.0 Dollars per Year

1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit

Benefit limitations may apply to individual services.

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

Limit: 1.0 Visit(s) per 6 Months

Limit: 3.0 Item(s) per Year

Covered when medically necessary.

Limit: 34.0 Days per Month

Members can obtain a 34 day supply through network pharmacies or home delivery. Members also have the option to receive a 102 day 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.

Exclusions: Health care services and related expenses for infertility treatments, including assisted reproductive technology, in vitro fertilization, in vivo fertilization, or any other medically-aided insemination procedure, regardless of the reason for the treatment, except when performed for the diagnosis, treatment and correction of the underlying causes of infertility.

Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). Depending upon where the covered service is provided, benefits will be the same as those stated under each health care service category.

Limit: 1000.0 Dollars per Year

1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit

Benefit limitations may apply to individual services.

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

Limit: 34.0 Days per Month

Members can obtain a 34 day supply through network pharmacies or home delivery. Members also have the option to receive a 102 day 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.

Medical or behavioral/mental health related nutritional education services that are provided as part of treatment for a disease are covered

Coverage is for medically necessary orthodontia only.

Limit: 90.0 Days per Year

Speech Therapy limited to 1 visit per day, up to 90 days.

Limit: 34.0 Days per Month

Members can obtain a 34 day supply through network pharmacies or home delivery. Members also have the option to receive a 102 day 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.

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: 90.0 Days per Year

Speech Therapy limited to 1 visit per day, up to 90 days.

Limit: 2.0 Visit(s) per Year

1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit

Limit: 1.0 Visit(s) per Year

Benefit also includes 1 pair of eyeglasses or contact lenses every 12 months. Eyeglass lenses have a $25 copay and frames are covered up to $150. Formulary contact lenses are covered in lieu of glasses with a $25 copay.

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

Limit: 34.0 Days per Month

Specialty medications are limited to a 34 day supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

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