Treatment must begin within 12 months of injury. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered.

Limit: 30.0 Visit(s) per Year

Chiropractic/Osteopathic and Manipulation Therapy. Visit limit applies separately to habilitative and rehabilitative services.

The per day inpatient copayment will apply for a maximum of three (3) days.

Including nutritional therapy

Benefit depends on place of treatment.

Includes orthotics and cochlear implants.

Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.

Ground, Air and Water transport. Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.

Limit: 1.0 Item(s) per Year

Limited to 1 pair of glasses (lenses and frames from pediatric selection) per calendar year. Therapeutic Contact Lenses are covered for a one year supply, regardless of the contact lens type, including professional services, in lieu of frame and lenses (may not receive contact lenses and frames in same benefit year). Elective Contact Lenses are covered for one pair or a single purchase of a supply of contact lenses in lieu of lenses and frame benefit (may not receive contact lenses and frames in same benefit year), including the professional services.

Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Physical Therapy and Occupational Therapy - 30 visits combined per year, Speech Therapy and Speech-Language Pathology (SLP) Services - 30 visits per year, Chiropractic/Osteopathic and Manipulation Therapy - 30 visits per year. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

Limit: 100.0 Visit(s) per Year

Coverage for custodial care, inpatient respite care, home health aide services, and homemaker services given by or under the supervision of a registered nurse. Bereavement services, both before and after the member?s death. Services for the surviving members of the immediate family for up to one year after the member?s death. Immediate family means all family members covered by this policy.

The per day inpatient copayment will apply for a maximum of three (3) days. Inpatient Room and Board, Lab and X-ray, Operating Room, etc. Out-of-Network: Emergency Services covered at In-Network cost share until transferable to an In-Network Hospital; if transferred to a Non-Participating Hospital services will no longer be covered and you will be responsible for 100% of the charges.

Refer to the policy for more information regarding Diabetes.

The per day inpatient copayment will apply for a maximum of three (3) days.

This benefit applies to All Other Outpatient Services excluding Office Visits. Please refer to the Specialist Office Visit benefit and to the SBC for more information. Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.

30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. Refer to the prescription drug list for more information.

Unlimited for diabetics and mental health/substance abuse diagnosis.

Physical Therapy and Occupational Therapy - 30 visits combined per year, Speech Therapy and Speech-Language Pathology (SLP) Services - 30 visits per year, Chiropractic/Osteopathic and Manipulation Therapy - 30 visits per year. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Routine physicals and other preventive services

Refer to the policy for more information about Virtual Care Services. In home visits by a Primary Care Physician are covered, refer to the policy for more information.

Limit: 16.0 Hours per Year

Included under Home Health Care Benefit

External and internal, includes components. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device.

Physical Therapy and Occupational Therapy - 30 visits combined per year. Visit Limit applies separately to habilitative and rehabilitative services. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

Limit: 30.0 Visit(s) per Year

Speech Therapy and Speech-Language Pathology (SLP) Services. Visit Limit applies separately to habilitative and rehabilitative services. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders.

Limit: 1.0 Visit(s) per Year

Limit: 100.0 Days per Stay

Includes Mental Health Office Visits and Substance Use Disorder Office Visits.

Including other high cost drugs. 30 day supply at any participating pharmacy or up to a 30 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

The per day inpatient copayment will apply for a maximum of three (3) days.

This benefit applies to All Other Outpatient Services excluding Office Visits. Please refer to the Specialist Office Visit benefit and to the SBC for more information. Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law.

Lifesource Travel benefit - unlimited, per insured person, per transplant

Out-of-network: You pay the same level as In-network if it is an emergency as defined in your plan, otherwise Not covered.