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Routine lab tests.

Hearing aids up to $400 every 36 months (toward the cost of hearing aids, fittings, evaluations, dispensing fees and/or repairs).

Motorized wheelchairs and scooters up to $2,500 lifetime maximum per member.

One wig (scalp hair prostheses) for a member each calendar year when hair loss is due to: chemotherapy; radiation therapy; infections; burns; traumatic injury; congenital baldness; and medical conditions resulting in alopecia areata or alopecia totalis (capitus).

Flu shots when furnished at a limited services clinic.

Space maintainers required due to premature loss of teeth.

Sealants applied to permanent premolar and molar surfaces (one application each 48 months for each premolar or molar surface).

Cosmetic services related to gender reassignment surgery. These covered services may include (but are not limited to): lip enhancement, liposuction of the waist, hair removal, hair transplants, surgery of the larynx, and lip reduction.

Voluntary sterilization procedures. Note: As a women's preventive health service, all female members have the right to full in-network coverage for sterilization procedures, provided the procedure is furnished for family planning reasons and it is performed as the primary surgical procedure. Any cost share amount for hospital services will still apply. (Self-referred benefits are limited to sterilization procedures when furnished for female members as the primary procedure for family planning reasons.)

Voluntary sterilization procedures. Note: As a women's preventive health service, all female members have the right to full in-network coverage for sterilization procedures, provided the procedure is furnished for family planning reasons and it is performed as the primary surgical procedure. Any cost share amount for hospital services will still apply. (Self-referred benefits are limited to sterilization procedures when furnished for female members as the primary procedure for family planning reasons.)