30 visit limits for PT and OT combined (including chiropractic).

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. Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period.

You pay a copayment for each 30 day supply. Up to a 30-day supply at a participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Combined 30 visit limit for occupational and physical therapies. Speech Therapy limited to 30 visits per year.

Limit: 1.0 Item(s) per 3 Years

Limited to one hearing aid, per hearing impaired ear, every 36 months.

Includes services related to the diagnosis, treatment and correction of conditions resulting in infertility. Excludes treatment of infertility such as in vitro fertilization and other types of artificial or surgical means of conception and associated procedures and the related medications are Not Covered.

Refer to the policy for more information regarding Diabetes.

This benefit applies to Mental Health Office Visits. All other Mental Health Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

You pay a copayment for each 30 day suppply, after deductible. Up to a 30-day supply at a participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy.

Limited to preventive services only, as part of the Preventive Care benefit.

Cardiac Rehabilitation limited to 30 visits per year; Pulmonary Rehabilitation limited to 1 course per year. Physical Therapy, Occupational Therapy, Chiropractic Care limited to 30 combined visits per year; Speech Therapy limited to 30 visits per year.

You pay a copayment for each 30 day supply, after deductible. Up to a 30-day supply at a participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. 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. Includes Mental Health Office Visits and Substance Use Disorder Office Visits.

Medically necessary care while receiving active care management, prior authorization required.

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

Limit: 30.0 Visit(s) per Year

Limit: 1.0 Visit(s) per Year

Children up to age 19. Limited to 1 visit per 12 month period.

Limit: 60.0 Days per Year

Including other high cost drugs. You pay a copayment for each 30day supply, after deductible. Up to a 30-day supply at a participating pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy.

This benefit applies to Substance Abuse Office Visits. All other Substance Abuse Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

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