be coordinated and authorized by acare 
manager. There is no cost to participate.   16 Summary of Benefits H5619075000SB23 H5619075000 
Chiropractic services 
Routine chiropractic: 
$0 copay per visit for up to 12 visits. 
Smoking cessation program 
To further assist in your effort to quit 
smoking or tobacco product use, we 
cover one additional counseling quit 
attempt within a12-month period as a 
service with no cost to you. This is in 
addition to the two counseling attempts