Summary Plan Description
This plan provides you with up to $325,000 of coverage for covered medical expenses each calendar year. Included within the $325,000 maximum are the following benefit maximums. If expenses exceed these maximums, this plan will not pay the additional costs. View previous policy
- Allergy testing—Blood testing for allergies is limited to 12 allergens per year. Skin testing for allergies is limited to 60 allergens per year.
- Autism spectrum disorders (children age twelve and under)—Annual maximum of 15 visits.
- Bariatric Surgery—Annual maximum of $15,000.
- Chemical dependency—Lifetime maximum of three episodes of treatment.
- Chiropractic care—Annual maximum of 24 spinal manipulations.
- Hearing aids—Maximum of $1,000 per ear paid in any three consecutive year period.
- Home health care—Annual maximum of 30 visits.
- Hospice care—Maximum of 14 inpatient days for hospice care. Skilled care in the home is limited to 60 visits. Respite care is limited to 120 hours per three-month period.
- Mental health (inpatient)—Annual maximum of 15 days.
- Mental health (outpatient)—Annual maximum of 30 visits.
- Neurodevelopmental therapy (children age six and under)—Annual maximum of 15 visits.
- Neuropsychological or psychological assessments or tests—Lifetime maximum of $1,200.
- Orthognathic surgery—Lifetime maximum of $5,000.
- Orthotics (foot)—Maximum of $400 paid in any two consecutive year period.
- Physical examinations—subject to the Preventive Health Benefit Schedule.
- Rehabilitation (inpatient)—Annual maximum of 15 days.
- Rehabilitation (outpatient)—Annual maximum of 30 visits.
- Skilled nursing facility—Annual maximum of 25 days.
- TMJ and MPDS—Lifetime maximum of $2,500.
- Transplants (donor organ procurement costs)—Maximum of $25,000 per transplant.
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