Per Indiana law, abortion only covered if performed because a woman becomes pregnant through an act of rape or incest; or an abortion is necessary to avert the pregnant woman?s death or a substantial and irreversible impairment of a major bodily function of the pregnant woman.

Cost share driven by provider/setting.

Cost share driven by provider/setting.

Limit: 12.0 Visit(s) per Benefit Period

Cost share driven by provider/setting.

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

Limit: 1.0 Visit(s) per 6 Months

One wig per benefit period.

Limit: 1.0 Item(s) per 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: 60.0 Visit(s) per Benefit Period

Includes 20 visits each of PT, OT and ST.

Limit: 100.0 Visit(s) per Benefit Period

Maximum does not include Home Infusion Therapy or Private Duty Nursing rendered in the home.

Cost share driven by provider/setting.

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).

Cost share driven by provider/setting.

Cost share driven by provider/setting.

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.

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

Limit: 60.0 Visit(s) per Benefit Period

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. 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). Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, 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. 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.

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.

Limit: 82.0 Visit(s) per Year

Must be medically necessary.

Cost share driven by provider/setting.

Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.

Limit: 40.0 Visit(s) per Benefit Period

Cost share is driven by provider/setting. Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to a separate 20 visits per benefit period. Coverage also includes an additional 20 visits each for habilitative services.

Limit: 20.0 Visit(s) per Benefit Period

Cost share driven by provider/setting.

Limit: 1.0 Visit(s) per Year

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

Limit: 90.0 Days per Benefit Period

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: 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.

Cost share driven by provider/setting.

Includes coverage for unrelated donor search services ($30,000 per transplant) and travel/lodging as approved by the plan ($10,000 per transplant).

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

Cost share driven by provider/setting.