An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

Minimum stay of 48 hours

Limit: 2.0 Visit(s) per Year

Various limitations apply as stated in the Benchmark plan.

The ER Copay is waived if the visit results in an inpatient admission.

Air ambulance services are covered in only specified situations.

Limit: 1.0 Visit(s) per Year

Quantity limits, authorizations and step therapy limits may apply.

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Limit: 1.0 Item(s) per 3 Years

Home Health Care services provided to a Member in lieu of an Inpatient Hospital Admission are covered; must obtain authorization.

Copays, if applicable, are per day for first three days only.

Lab services in the Emergency Room are subject to the deductible, if applicable.

An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.

Inpatient treatment for mental/behavioral health disorders must be Authorized as provided in the Care Management Article of this Benefit Plan.

Quantity limits, authorizations and step therapy limits may apply.

Limit: 4.0 Visit(s) per Benefit Period

Coverage only for diabetes education.

Medically Necessary orthodontia only.

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

Quantity limits, authorizations and step therapy limits may apply.

Quantitative limit units apply, see Benchmark plan.

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

Limit: 150.0 Hours per Benefit Period

Inpatient private-duty nursing services are not covered.

Various limitations apply as stated in the Benchmark plan.

Plan only outlines benefits for breast reconstruction. Must be medically necessary and related to mastectomy.

Rehabilitative Occupational and Physical Therapies are included in the Outpatient Rehabilitation Services benefit listed in Line 91 above.

Rehabilitative Speech Therapy is included in the Outpatient Rehabilitation Services benefit listed in Line 91 above.

Limit: 2.0 Visit(s) per Year

Covers exam and cleaning

Limit: 1.0 Visit(s) per Year

An added benefit

Limit: 1.0 Visit(s) per Year

Three-day prior inpatient stay

Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply.

Inpatient treatment for substance abuse must be Authorized as provided in the Care Management Article of this Benefit Plan, when coverage for alcohol and/or drug abuse is provided.

Covered Services will be only those, which are for treatment for abuse of alcohol, drugs or other chemicals, and the resultant physiological and/or psychological dependency, which develops with continued use.

Exclusions: Non-EHB and out-of-network transplant services

Exclusions: Non-Vantage Weight Loss programs are excluded.

Vantage Weight Loss programs are covered as part of the Vantage Wellness Program.