Summary Plan Description

Chiropractic Care

80% Network and Non-Network

Benefits are provided for chiropractic care for the manipulation of the spine and supporting structures with a calendar year maximum of 24 visits. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or $4,000 out-of-pocket maximums. Services and supplies include:

  • Initial office call and evaluation per spinal condition.
  • Initial plane film diagnostic x-rays of the spine per condition performed or ordered for chiropractic care.
  • Spinal manipulations.

Benefits are not provided for:

  1. Manipulations of any parts of the body which are not articulations of the spine.
  2. Treatment which is not within the scope of the covered provider's license.
  3. Office calls in addition to spinal manipulations on the same day, except as provided above.
  4. Physical therapy or modalities.
  5. Massage therapy.
  6. Treatment by machine including, but not limited to, vibrasonic therapy, ultrasound therapy, hydrotherapy.
  7. Acupuncture.