Limit: 35.0 Visit(s) per Year

Continuous glucose monitors and related supplies are covered under DME.

NonNetwork nonemergency ambulance services are subject to the same Cost Share as Network services up to $50,000 per trip.

Frames and lenses or contat lenses are covered once per benefit period. Limit is comnbined in network and out of network.

Retail Pharmacy is limited to a 30-day supply per Prescription.

Limit: 35.0 Visit(s) per Year

Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.

Limit: 1.0 Item(s) per 3 Years

Services to restore loss of or correct an impaired speech or hearing function with hearing aids are covered as any other sickness.

Limit: 60.0 Visit(s) per Year

Limited to a maximum of 60 visits per Member per Calendar Year

Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.

The cost sharing that displays applies to outpatient office visits. Similar services provided in an Outpatient Hospital setting may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Retail Pharmacy is limited to a 30-day supply per Prescription.

Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.

Limit: 35.0 Visit(s) per Year

Limit is combined for rehabilitative physical therapy and manipulation therapy.

Retail Pharmacy is limited to a 30-day supply per Prescription.

Office visit Copayment limit is combined for visits In Office, Telehealth, Telemedicine, Outpatient Mental Healthcare and Outpatient Substance Services. You have $0 virtual visits and medical chats using our preferred virtual care-only Primary Care Physicians (PCP). These services can be accessed via our Sydney application or member website.

Limit: 35.0 Visit(s) per Year

Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Limit is combined for rehabilitative physical therapy and manipulation therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.

Limit: 35.0 Visit(s) per Year

Limit is combined for rehabilitative and habilitative physical therapy, occupational therapy and speech therapy. Services submitted with an Autism diagnosis are unlimited for physical, occupational and speech therapy.

Eye exams are covered once per benefit period. Limit is combined in network and out of network for the exam.

Limit: 25.0 Days per Year

Limited to a maximum of 25 days per Member, per Calendar Year

Specialty Drugs must be purchased from the Pharmacy Benefits Manager?s Specialty Pharmacy and are limited to a 30-day supply.

The cost sharing that displays applies to outpatient office visits. Similar services provided in an Outpatient Hospital setting may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

Transportation and lodging are not covered out of network. Donor search charges are limited to 10 best matched donors per transplant, identified by an authorized registry.