Limit: 26.0 Visit(s) per Year

Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self-dialysis. 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. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses for Children- One pair or one box per eye of contact lenses, including professional services ? in lieu of lenses and frame 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 Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Physical Therapy - 20 visits per year; Occupational Therapy- 20 visits per year; Speech Therapy- unlimited visits per year. PCP copay applies for Physical Therapy and Occupational Therapy visits.

Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.

Limit: 100.0 Visit(s) per Year

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

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.

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy.

Benefit depends on type of service provided.

Physical Therapy - 20 visits per year; Occupational Therapy- 20 visits per year; Speech Therapy- unlimited visits per year. Cardiac Rehabilitation -36 visits per year; Pulmonary Rehabilitation - 20 visits per year. PCP copay applies for Physical Therapy and Occupational Therapy visits.

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

Refer to the policy for more information about Virtual Care Services.

Limit: 82.0 Visit(s) per Year

Limited to Home Health Care Services

20 visits for Physical Therapy and an additional 20 visits for Occupational Therapy.

Unlimited visits for speech therapy.

Limit: 1.0 Visit(s) per Year

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

Coverage is available if Medically Necessary.

Limit: 150.0 Days per Year

Including other high cost drugs. Up to a 30-day supply at any Participating Pharmacy or up to a 30-day supply at a Designated 90 day Retail Pharmacy.

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.

Lifesource Travel maximum of $10,000 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.