• Annual gynecological exam, PFFS only (PDF)
• Annual gynecological exam, PPO only (PDF)
• Bathroom safety items (PDF)
• Blood and blood components, PFFS only (PDF)
• Blood and blood components, PPO only (PDF)
• Chiropractic care (PDF)
• Chiropractic care, PPO Group (PDF)
• Contraceptive devices (PDF)
• Dental care (PDF)
• Determination of refractive state (PDF)
• Emergency department care (PDF)
• Foreign travel: Nonemergent, nonurgent care (PDF)
• Gradient compression stockings (PDF)
• Hearing services, PPO only (PDF)
• Home infusion therapy (PDF)
• Hospice care (PDF)
• Human organ transplant (PDF)
• Inpatient hospital care (PDF)
• LASIK, radial keratotomy (PDF)
• Outpatient rehabilitation therapy caps (PDF)
• Private duty nursing (PDF)
• Remote patient monitoring, PPO only (PDF)
• Remote patient monitoring, PFFS only (PDF)
• Routine physical examinations (PDF)
• SilverSneakers^® fitness, PPO only (PDF)
• Skilled nursing facility (PDF)
• Sterilization (PDF)
• Total body skin examination (PDF)
• Vision care (PDF)
• Worldwide coverage - emergency and urgent care, PPO only (PDF)