• 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)
• Gradient compression stockings, PPO only (PDF)
• Hearing services, PPO only (PDF)
• Home infusion therapy (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)