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Acupuncture furnished by a Physician or any Licensed Acupuncturist up to 15 visits for each member in each calendar year. (This includes acupuncture to treat a medical condition and/or when it is used in place of anesthesia for covered surgery.)

In addition, this health plan covers one set of frames and/or prescription lenses (or contact lenses instead) for each member in each calendar year. For covered vision supplies, benefits are provided for up to:

$100 for single lenses or contact lenses.

$115 for bifocal lenses.

$125 for trifocal lenses.

$250 for contact lenses after cataract surgery.

One routine mammogram each calendar year.

Semiprivate room and board and special services furnished by the hospital. (Private room charges may be covered when Blue Cross Blue Shield determines that the room is medically necessary for the member's condition.)

Semiprivate room and board and special services furnished by the hospital. (Private room charges may be covered when Blue Cross Blue Shield determines that the room is medically necessary for the member's condition.)

Semiprivate room and board and special services furnished by the hospital. (Private room charges may be covered when Blue Cross Blue Shield determines that the room is medically necessary for the member's condition.)