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: 25.0 Visit(s) per Year

Cosmetic Procedures are excluded from coverage. Cosmetic Procedures do not include reconstructive procedures for treatment of a Congenital Anomaly of a newborn child or Medically Necessary breast reduction surgery.

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

Limit: 1.0 Visit(s) per 6 Months

Limit: 1.0 Item(s) per Year

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: 2.0 Item(s) per 3 Years

Benefits are available to Covered Persons of any age, and are limited to one hearing instrument (hearing aid) per hearing impaired ear every 36 months for a hearing aid that is purchased due to a written recommendation by a Physician.

Limit: 6.0 Procedure(s) per Lifetime

The maximum number of completed oocyte retrievals that are eligible for coverage under this Certificate in your lifetime is six. Following the final completed oocyte retrieval, benefits will be provided for one subsequent procedure to transfer the oocytes or sperm to you.Thereafter, you will have no benefits for infertility treatment.

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: 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

Coverage is for medically necessary orthodontia only.

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.

Exclusions: Inpatient Private Duty Nursing Service is not covered.

Private Duty Nursing services will be covered as a part of the Home Health Care benefit.

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

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.