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o Bitewing x-rays once per year o Full mouth x-rays once every three years • Therapeutic pulpotomy

The maximum annual benefit shall not exceed $600 per child per year.

6.2.18 Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18))

Limited to two 5-day detox stays per lifetime; plus one 28-day lifetime stay.

6.2.19 Outpatient substance abuse treatment services (Section 2110(a)(19))

Limited to 52 sessions mental health and substance abuse combined.

6.2.20 Case management services (Section 2110(a)(20)) 6.2.21 Care coordination services (Section 2110(a)(21)) 6.2.22 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22))

Limited to 52 visits per year per condition.

6.2.23 Hospice care (Section 2110(a)(23))

6.2.24 Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services (See instructions) (Section 2110(a)(24))

Vision Care which includes the following:

• Annual vision exam (including refractive exam and glaucoma testing) • Prescription eyeglass lenses including bifocal or trifocal, fitting and dispensing fee (once every 12 months - $ 85 maximum) • Eyeglass frames (including routine replacement once every 24 months - $100 maximum). • Prescription contact lenses in lieu of eyeglasses (once every 12 months - $150 maximum)

Approved optical services, supplies, and solutions must be

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