Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Limit: 1.0 Item(s) per Year

OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-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 90 day retail pharmacy. Refer to the prescription drug list for more information.

Limit: 25.0 Visit(s) per Year

Per year, limited to 25 visits combined (occupational, speech and physical therapy). Inpatient habilitation services limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 2.0 Item(s) per Benefit Period

One hearing aid per ear every 4 years.

Limit: 30.0 Visit(s) per Year

Exclusions: Excludes respite care.

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

Limit: 25.0 Visit(s) per Year

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Prior authorization may be required - please contact the number listed on your ID card.

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

Limit: 25.0 Visit(s) per Year

Per year, limited to 25 visits combined (occupational, speech and physical therapy). Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 85.0 Visit(s) per Year

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality... 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

Limit: 25.0 Visit(s) per Year

Maximum of 25 outpatient visits for physical therapy, occupational therapy and speech therapy (combined). Inpatient rehabilitation limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 25.0 Visit(s) per Year

Maximum of 25 outpatient visits for physical therapy, occupational therapy and speech therapy (combined). Inpatient rehabilitation limited to 30 days per year. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 1.0 Exam(s) per Year

OON exam: Up to $38.50. Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eyeglasses. OON eyewear benefit: covered up to $50 for frames, lenses up to $37.50 and contact lenses up to $91.

Limit: 1.0 Exam(s) per Year

Up to $38.50 OON

Limit: 30.0 Days per Year

Prior authorization may be required - please contact the number listed on your ID card.

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization.

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.