- 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)