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

Limit: 20.0 Visit(s) per Year

Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year.

Limit: 2.0 Exam(s) per Year

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: 45.0 Visit(s) per Year

Nebraska supplemented this EHB category for Habilitative Services: 'Health care Services that help a person keep, learn, or improve skills and functioning for daily living. These Services may include physical and occupational therapy, speech language pathology and other Services for people with disabilities in a variety of Inpatient and/or Outpatient settings.' Quantitative limits on services apply to outpatient, only.

Coverage is applicable for the following items provided to a child under the age of 19: A hearing aid purchased from a licensed audiologist with the medical clearance from an otolaryngologist and costs related to dispensing such hearing aid, evaluation of a hearing aid, fitting of a hearing aid, and programming of a hearing aid. Coverage includes one (1) Hearing Aid per Hearing Impaired ear up to $3,000 every 48 months.

Limit: 60.0 Days per Year

Benefit limit will be 60 days per calendar year for home health aide

The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.

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

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

Limit: 45.0 Visit(s) per Year

Limits apply to Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar 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.

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: 45.0 Visit(s) per Year

Limits apply to physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).

Limit: 45.0 Visit(s) per Year

Limits apply to physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).

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 Exam(s) per Year

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

Limit: 60.0 Days per Year

Skilled Nursing Facility limited to 60 days per year. Inpatient Rehabilitation Facility Services are not subject to this limit.

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.