(includes limitations and exclusions)

Select a service for details about plan benefit coverage:

Please select an item. Abortion Allergy Serum Allergy Services Alternative Therapies Ambulance Service Annual Physical Exam Autopsy Bariatric Surgery Birth Control Prescriptions and Devices Blood Storage Breast Augmentation Mammoplasty Cardiac & Pulmonary Rehabilitation Care Received Without Charge Charges Resulting From Your Failure to Appropriately Cancel a Scheduled Appointment Chiropractic Benefits Cochlear Implant Device Comfort/Convenience Items Cosmetic/Reconstructive Surgery Custodial or Domiciliary Care Deductible Dental Care/Accidental Injury Dental Exclusions Durable Medical Equipment/Disposable Supplies Durable Medical Equipment/Medically Necessary Disposable Supplies Educational or Psychological Testing Emergency Room Services Examinations (Requested by third party) Excessive Charges Exercise Equipment Experimental Services Eye Glasses and Contact Lenses Eye Services Government Facility Growth Hormone Therapy Hair Analysis, Wigs, and Hair Transplants Hair Prosthesis Health and Athletic Club Membership Hearing Aids Hearing Testing Home Health Care/Rehabilitation Services Performed at Home Hospice Care Hospital Benefits - Inpatient Room & Board Immunizations Immunizations (Requested by third party or for travel) Infertility Infertility Exclusions Injections Level of Care Mammograms Mastectomies Maternity Coverage Medical Care and Supplies Medical Service Performed by Family Member Military Service - Connected Injury/Illness Non-Network Providers Not Medically Necessary Services Nutrient Supplements Nutritional Counseling Obesity Oral Surgery Orthognathic Surgery Orthoptics Orthotics Other Charges Outpatient Benefits for Mental & Nervous Disorder/Chemical Dependency Outpatient Diagnostic Lab & X-ray Outpatient Diagnostic Procedures Over-the-Counter Medications Over-the-Counter Supplies Oxygen Physical Fitness Physical, Speech and Occupational Therapy & Rehab Services-Outpatient Physician Charges Plan Maximum Pre-existing Conditions Prescription Drugs Preventive Services Private Duty Nursing Prosthetic Repair or Replacement Prosthetics Services Not Specifically Included as Benefits Services Rendered After Termination of Coverage Skilled Nursing Facility Smoking Cessation Speech Therapy Stimulators (For bone growth) Surgery Including Sterilization Surrogacy Temporo-Mandibular Joint Syndrome (TMJ) Transplants Transsexual Surgery Travel Expenses Travel Expenses for Transplants Treatment for Disorders Relating to Delays in Learning, Motor Skills and Communication Trimming of Nails, Corns or Calluses Urgent Care Usual, Customary and Reasonable (UCR) Vision - Routine Exam Vitamins/Nutrients (Through ESI Pharmacy Benefit) War or Insurrection Well-Child Care Wellness Exams for Men and Women Workers Compensation