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.

Limit: 12.0 Visit(s) per Benefit Period

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

Limit: 1.0 Exam(s) per 6 Months

Limit: 1.0 Item(s) per Year

Excluded from In-Network Out-of-Pocket Limit

Limit: 1.0 Item(s) per Year

Covered when medically necessary.

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 Year

Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, and 20 visits per year for Physical Therapy. Visit limits do not apply for therapies for covered persons with a primary diagnosis of Autism Spectrum Disorder.

Cochlear implants are covered as durable medical equipment.

Limit: 100.0 Visit(s) per Year

The 100 visit/year limit is not applicable to home infusion therapy or private duty nursing rendered in the home setting.

Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage 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.

Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information.

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.

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

Coverage is for medically necessary orthodontia only.

Limit: 60.0 Visit(s) per Year

Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, 20 visits per year for Physical Therapy, 36 visits per year for Cardiac rehabilitation Therapy, and 20 visits per year for Pulmonary rehabilitation therapy.

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: 90.0 Visit(s) per Year

Private Duty Nursing Services are Covered Services only when provided through the Home Health Care Services benefit.

Limit: 40.0 Visit(s) per Year

Limited to 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy.

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year for Speech Therapy

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.

Limit: 1.0 Visit(s) per Year

Covered when done for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease

Limit: 90.0 Days per Year

Limit will be 90 days per benefit period for Skilled Nursing Facility. Limits will be 60 days per benefit period for inpatient physical medicine and rehabilitation.

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 sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information.