Services must begin within 12 months of the date of injury; diagnosis made within 6 months of date of injury.

Limit: 24.0 Visit(s) per Year

Services must be medically necessary to relieve pain, induce surgical anesthesia, or to treat a covered illness, injury or condition.

Frequency limits apply to some services.

Limit: 24.0 Visit(s) per Year

Orthotics or orthopedic shoes are covered when medically necessary.

Air and Ground transpiration benefit is limited to medical emergency. Ambulance services is separate benefit.

Limit: 1.0 Item(s) per Year

Information about gender affirming care can be found in the policy.

Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.

Limit: 45.0 Visit(s) per Year

Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition.

Limit: 130.0 Visit(s) per Year

130 visits per year applies to home visits of a home health care provider or one or more: registered nurse; a licensed practical nurse; a licensed physical therapist or occupational therapist; a certified respiratory therapist; a speech therapist certified by the American Speech, Language, and Hearing Association; a licensed social worker.

Inpatient hospice care up to a maximum of 10 days. Respite care, up to a maximum of 240 hours, to relieve anyone who lives with and cares for the terminally ill member.

Frequency limits apply to some services.

Exclusions: Biofeedback is limited to the treatment of migraine headaches.

Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.

Medically necessary repair of disabling malocclusion or cleft palate and severe craniofacial defects impacting function of speech, swallowing and chewing.

Covered only when the provider is licensed to practice where the care is provided, is providing a service within the scope of that license, is providing a service or supply for which benefits are specified in this plan, and when benefits would be payable if the services were provided by a physician.

Limit: 45.0 Visit(s) per Year

Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition.

Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.

Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5.

Benefit limited to initial purchase of prosthetic; does not cover replacement unless the existing device can?t be repaired, or replacement is prescribed by a physician because of a change in your physical condition.

Breast reconstruction allowed.

Limit: 45.0 Visit(s) per Year

Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition.

Limit: 45.0 Visit(s) per Year

Outpatient rehabilitation/habilitation includes physical, speech and occupational therapy and cardiac and pulmonary rehabilitation combined, and is subject to an annual visit limit. There is no annual limit for care for autism spectrum disorders provided. Limits apply separately to rehabilitative and habilitative services. Services to treat intractable or chronic pain are subject to the annual limit. Benefits are not provided for both chronic pain care and neurodevelopmental therapy for the same condition.

Limit: 1.0 Exam(s) per Year

1 exam per year

Limit: 1.0 Exam(s) per Year

Covered if required for the member?s medical condition.

Limit: 60.0 Days per Year

Up to 90-day supply for retail and mail order (one copay for each 30 day supply); up to 30 day supply per prescription for specialty pharmacy.

Well Baby Exams covered for the first 24 months of life; 3 exams age 2-4; one exam per year age 5+; Newborn Hearing Screening within 30 days of birth. Additional tests up to age 24 months; Routine Vision Screening age 3-5.