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

 

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