Outpatient Services

Acupuncture, is covered when it's used:
as a form of pain control, or
for treatment of nausea because of chemotherapy, pregnancy or post-operative procedures;

Allergy testing and treatment;
Chemotherapy and radiation treatments;
Chiropractic care when medically necessary as determined by the claims administrator to diagnose or treat illness, injury, or disease. Coverage is limited to 20 visits per year (including initial consultation) and ends once maximum medical recovery has been achieved and treatment is primarily for maintenance or managing pain;
Diagnostic services, including:
EEG, EKG, and other medical electronic procedures;
Laboratory and pathology tests; and
Radiology services.
Education therapy, but only for participants with a diagnosis of diabetes mellitus;
Eye exams for patients with diabetes (covered as a specialist office visit);
Hemodialysis provided at a free-standing facility such as a dialysis center or your home, when ordered by a licensed provider;
Home health care, which may require precertification; limited to a maximum of 200 visits/calendar year; one visit = four hours. (Please see "Mental Health Benefits" for more information.) The attending physician must submit a detailed description of the medical necessity and scope of services provided to the claims administrator. The following are covered if ordered by the physician under the home health care plan and provided in the patient's home:
Medical supplies and laboratory services prescribed by a physician;
Nutrition counseling provided by or under the supervision of a registered dietitian;
Part-time or intermittent nursing care provided or supervised by a registered nurse (R.N.), a licensed practical nurse (L.P.N.), or a licensed vocational nurse (L.V.N.);
Part-time or intermittent home health services, primarily for the patient's medical care; and
Physical, occupational, speech, or respiratory therapy by a licensed qualified therapist.
Licensed, general hospital emergency room use for treatment of an injury or sudden illness, including:
Emergency treatment rooms;
Laboratory and pathology tests;
Licensed providers' services;
Supplies and medicines administered during the visit; and
Radiology services.
Licensed provider-prescribed respiratory therapy approved by the claims administrator;
Mental health care/substance abuse care;
Occupational therapy rendered by a licensed therapist, up to a combined total of 60 in- and out-of-network visits per calendar year. (There is no visit limitation for those with an underlying mental health diagnosis. Please see "Mental Health Benefits" for more information.)
Outpatient surgery and related follow-up care;
Physical therapy rendered by a licensed therapist, up to a combined total of 60 in- and out-of-network visits per calendar year. (There is no visit limitation for those with an underlying mental health diagnosis. Please see "Mental Health Benefits" for more information.)
Podiatric care when medically necessary as determined by the claims administrator to diagnose or treat illness, injury, or disease. Coverage ends once maximum medical recovery has been achieved and treatment is primarily for maintenance or managing pain;
Prenatal care;
Speech therapy rendered by a licensed therapist, up to a combined total of 60 in- and out-of-network visits per calendar year. (There is no visit limitation for those with an underlying mental health diagnosis. Please see "Mental Health Benefits" for more information.)
Temporomandibular joint syndrome (TMJ) medical treatment only; including exams, X-rays, injections, anesthetics, physical therapy, and oral surgery up to $1,000 combined in-network and out-of-network maximum per year (appliances are not covered); and
Virtual doctor.