Limited to treatment for accidental injury to natural teeth within six months of the accidental injury.

Benefit depends on type of service provided

Limit: 25.0 Visit(s) per Year

Includes an additional 15 visits per year for Naprapathic Services.

Cosmetic surgery for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

Benefit depends on place of treatment

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

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

Children up to age 19, through the end of their birth month. Limit 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. One pair of contact lenses - in lieu of lenses and frames benefit, (may not receive contact lenses and frames in same benefit year).

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. Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 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.

Includes unlimited Physical, Speech and Occupational Therapies.

Limit: 1.0 Item(s) per 2 Years

Hearing aids for adults and children, 1 per ear every 24 months. Includes bone anchored hearing aids (BAHAs) with no maximum.

Includes Respite care.

Benefit depends on type of service provided

Some laboratory tests for Diabetes are covered at no charge. Refer to the policy for more information regarding Diabetes.

This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information.

Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy.

Cardiac rehab limited to a maximum of 36 Outpatient treatment sessions within a 6 month period. Physical, Occupational and Speech Therapies are Unlimited.

Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services

Physical, Occupational and Speech Therapy- Unlimited. Includes medically necessary preventive physical therapy for members diagnosed with multiple sclerosis.

Unlimited Speech Therapy.

Limit: 1.0 Exam(s) per Year

Children up to age 19, through the end of their birth month.

Services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary as part of another Covered Service.

Including other high cost drugs. Up to a 30-day supply at any designated pharmacy or up to a 90-day supply at any designated 90 day retail pharmacy.

This benefit applies to all other Outpatient Services excluding Office Visits. Substance Use Disorder Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information.

Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. You pay a copayment for each 30 day supply.

LifeSource Facility Travel Maximum: $10,000 per insured person, per transplant and a maximum reimbursement of $50 for lodging per person, per day.

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