Wellpoint Essential Silver 3500 ($0 Virtual PCP + $0 Select Drugs + Incentives) - 44228FL0040012 Health Insurance Plan

no coverage except limited to therapeutic coverage (only in case of rape, incest or health of mother)

Limit: 3000.0 Dollars per Episode

Exclusions: Damage to teeth due to chewing or biting is not deemed an accidental injury and is not covered.

Cost share will vary by the specific service rendered. Accident must have occurred on or after your effective date and treatment within 12 months of an accidental injury.

Cost share will vary by the specific service rendered.

Limit: 35.0 Visit(s) per Year

Limit is combined across professional visits and outpatient facilities for Osteopathic/Chiropractic Manipulation Therapy. These services are not covered in the home.

Coverage includes inpatient maternity care in a Hospital for the mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. Covered services include at-home post delivery care visits at your residence by a Physician or Nurse performed no later than 72 hours following you and your newborn child?s discharge from the hospital.

Wigs are limited to 1 wig per Member, per Benefit Period after cancer treatment. Coverage includes 4 surgical bras per benefit period.

Copay waived if admitted.

Nonemergency Ambulance Services must be Preauthorized by Us.

Limit: 1.0 Item(s) per Year

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

Cost share reflects a 30 day retail supply

Benefits include treatment of Autism Spectrum disorder for children ages 0-21. Applied Behavioral Analysis is limited to 20 hours per week. Limit is combined across professional visits and outpatient facilities.

Cochlear implants are covered as durable medical equipment (DME).

Limit: 100.0 Visit(s) per Year

Benefit limit does not apply to Home Infusion Therapy or Home Dialysis.? Private Duty Nursing is only covered through Home Health Care Services and is limited to 90 visits per calendar year, which is separate from the 100 visits a year limit for "other" Home Health Care services. Benefit limit does not apply to Physical, Occupational or Speech Therapy when performed as part of Home Health.

Includes services to diagnose and treat MEDICAL conditions resulting in infertility. Excludes: Artificial insemination, in vitro fertilization, other types of artificial or surgical means of conception including drugs administered in connection with these procedures.

Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy. Home Infusion Therapy is not included in the Home Health Care visit maximum

Inpatient Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis) is limited to a maximum of 60 days per member, per calendar year. Coverage includes inpatient maternity care in a hospital for the mother, and inpatient newborn care in a hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is medically necessary.

The cost sharing that displays applies to outpatient office visits. Facility charges for similar services in an Outpatient Hospital setting could be subject to additional cost sharing. Please refer to the plan policy documents to determine if your plan may have a higher cost share in an Outpatient Hospital setting.

Cost share reflects a 30 day retail supply

Covered benefit under Home Health Services or covered as US Preventive Services Task Force (USPSTF) A or B recommendation under preventive health services, which includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors.

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: 105.0 Visit(s) per Year

Limit is combined to 35 visit each for Physical Therapy, Occupational Therapy and Speech Therapy

Cost share reflects a 30 day retail supply

Services related to surrogacy are excluded if the member is not the surrogate.

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

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.

Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.

Cost shares may vary based on the setting in which Covered Services are received.

Limit: 40.0 Visit(s) per Year

20 visits per person per year for Physical Therapy and a separate 20 visits for Occupational Therapies. Autism limits are separate from Rehabilitation limits for Physical and Speech Therapy. Limit is combined across professional visits and outpatient facilities.

Limit: 20.0 Visit(s) per Year

Autism limits are separate from Rehabilitation limits for Physical and Speech Therapy. Limit is combined across professional visits and outpatient facilities.

Limit: 1.0 Exam(s) per Year

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

Limit: 60.0 Days per Year

Custodial or residential care in a skilled nursing facility or any other facility is not covered except when rendered as part of hospice care.

Cost share reflects a 30 day retail supply

The cost sharing that displays applies to outpatient office visits. Facility charges for similar services in an Outpatient Hospital setting could be subject to additional cost sharing. Please refer to the plan policy documents to determine if your plan may have a higher cost share in an Outpatient Hospital setting.

Transportation and lodging limited to $10000/transplant per benefit paid. The Plan will provide assistance with reasonable and necessary travel expenses when patient is required to travel more than 75 miles from residence to reach the facility where the Covered Transplant Procedure will be performed. If the Member receiving treatment is a minor, then reasonable and necessary expenses for transportation and lodging may be allowed for two companions. Unrelated Donor Search is Limited to a maximum of the 10 best matched donors, identified by an authorized registry

Limited to one splint in a six-month period, unless a more frequent replacement is determined by Us to be Medically Necessary.

Urgent Care center services received outside of the service area are not covered, unless the service is rendered at a BlueCard facility. If out of area Urgent Care services are rendered at a BlueCard facility, the cost share is the same as In Network.