Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: Cosmetic surgery is covered only for certain conditions. It is not covered for cosmetic surgery or complications resulting therefrom, including Surgery to improve or restore your appearance, unless needed to repair conditions resulting from an accidental injury; or for the improvement of the physiological functioning of a malformed body member resulting from a congenital defect. In no event will any care and services for breast reconstruction or implantation or removal of breast prostheses be a Covered Service unless such care and services are performed solely and directly as a result of mastectomy which is medically necessary.

Cosmetic surgery is covered only for certain conditions. It is not covered for cosmetic surgery or complications resulting therefrom, including Surgery to improve or restore your appearance, unless needed to repair conditions resulting from an accidental injury; or for the improvement of the physiological functioning of a malformed body member resulting from a congenital defect. In no event will any care and services for breast reconstruction or implantation or removal of breast prostheses be a Covered Service unless such care and services are performed solely and directly as a result of mastectomy which is medically necessary.

Childbirth/delivery professional services are subject to your Medical EHB Deductible/Maximum Out of Pocket for Medical EHB benefits, if applicable. Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details.

Limit: 1.0 Item(s) per Benefit Period

Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain generic drugs may have a higher cost share amount than is listed on this page. When prescription drugs are bought from an out of network pharmacy additional charges may apply. See benefit book for details.

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

1 hearing aid per ear (2 hearing aids) every 48 months for any covered member.

Limit: 30.0 Visit(s) per Benefit Period

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Covered when medically necessary.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

When prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care.

Limit: 85.0 Visit(s) per Benefit Period

Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Limit: 25.0 Visit(s) per Benefit Period

Limit is combination of Speech Therapy, Occupational Therapy, Physical Therapy, and Muscle Manipulations.

Limit: 1.0 Visit(s) per Benefit Period

When purchasing Out of Network, reimbursements are available. See benefit book for details.

Covered when medically necessary.

Limit: 30.0 Days per Benefit Period

Exclusions: Coverage for certain agents or medication categories may also be excluded. These include, but are not limited to: Weight Loss, Impotency, OTC Equivalents, Fertility and Compounds. Any drug not found on the drug list is not covered. See benefit book for further details.

Certain specialty drugs may have a higher cost share amount than is listed on this page. If prescription drugs are bought from an out of network pharmacy additional charges may apply. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details.

Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details.

Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details.