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This health plan covers routine GYN exams, including routine Pap smear tests, furnished by a General Hospital, Community Health Center, Physician or Independent Lab.

This health plan covers family planning services furnished by a Community Health Center, General Hospital or Physician. These covered services include:

This health plan provides emergency coverage only when covered services are received in the service area. These emergency medical services may include inpatient or outpatient services by providers qualified to furnish emergency medical care and that are needed to evaluate or stabilize the member's emergency medical condition. The member does not need a PCP referral or approval from Blue Cross Blue Shield before obtaining emergency medical care. (Refer to Inpatient Medical and Surgical Care in a General Hospital for information about inpatient benefits.)

This health plan covers medically necessary short-term rehabilitation therapy (including habilitation services) furnished by a General, Chronic Disease or Rehabilitation Hospital, Skilled Nursing Facility, Community Health Center, Physical Therapist or Occupational Therapist. These covered services include:

Endosteal implants to replace permanent teeth for members age 16 or older, includes fixture, abutment and implant crown (once each 60 months for each tooth).

Metallic, porcelain and composite resin inlays for members age 16 or older (once each 60 months for each tooth).

Replacement of metallic, porcelain and composite resin inlays for members age 16 or older (once each 60 months for each tooth).

This health plan covers medically necessary short-term rehabilitation therapy furnished by a General, Chronic Disease or Rehabilitation Hospital, Skilled Nursing Facility, Community Health Center or Occupational Therapist up to the number of visits described in the benefit limit. These covered services include:

These benefits for removal of impacted teeth are limited to a combined maximum of $2,500 for each member in each group plan year for inpatient and outpatient services.

One visit each group plan year for ages 2 through 18.