AmeriHealth Caritas Next Gold Signature + No Referrals - 67926FL0010004 Health Insurance Plan

Limit: 30.0 Visit(s) per Benefit Period

Limited to 30 visits per benefit period. More available beyond the initial allotment if deemed medically necessary.

Services must be covered from birth until age 16 and exempt from deductibles. Must receive periodic visits, appropriate immunizations, and laboratory tests.

Limit: 35.0 Visit(s) per Benefit Period

Exclusions: The following are specifically excluded from chiropractic care and osteopathic services: Charges for care not provided in an office setting, Chelation therapy, Maintenance or preventive treatment consisting of routine, long-term, or not medically necessary care provided to prevent reoccurrences or to maintain the patient?s current status, Manipulation under anesthesia, Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law, Vitamin or supplement therapy.

Combined limit for all outpatient therapy plus chiropractic. Includes Massage Therapy and Spinal Manipulation.

Coverage must include medical, dental, speech therapy, audiology, and nutrition services but only if these services are prescribed by the treating physician or surgeon and the physician or surgeon certifies that the services are medically necessary and consequent to treating the cleft lip or cleft palate.

Exclusions: Maternity services rendered to a covered person who is acting as a gestational surrogate are excluded and for services related to surrogate parenting

Newborn must be covered for injury, sickness, or the cost of transporting the newborn to the nearest available facility that is appropriately stafffed. Coverage for transportation may not exceed the usual and customary charges, up to $1,000. Post partum assessment and newborn assessment must be performed.

Coverage required until the age of 25.

Limit: 1.0 Item(s) per Benefit Period

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

Exclusions: For outpatient habilitative and rehabilitative services for which there is no reasonable expectation of acquiring, restoring, improving or maintaining a level of function

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Limit: 20.0 Days per Benefit Period

Exclusions: Part-time- Services limited to less than 8 hours a day, less than 40 hours a week. Intermittent- Services limited to each visit up to but not exceeding 2 hours a day. Excluded: Services rendered by an employee/operator of an adult congregate living facility, adult foster home, adult day care center, or a nursing facility.

Coverage for at least the following: (a)Baseline mammogram for any woman who is 35 or older, but younger than 40. (b) Mammogram every 2 years for any woman who is 40 or older, but younger than 50 or more frequently based on the patient's physician's recommendation. (c) A mammogram every year for any woman who is 50 or older. (d) One or more mammograms a year, based on a physician's recommendation for any woman who is at risk for breast cancer

Includes post-mastectomy care.

Exclusions: Excludes services for psychological testing associated with the evaluation and diagnosis of learning disabilities or for mental retardation.

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply.

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

Diabetes coverage includes nutrition counseling; home health services include nutritional guidance.

Exclusions: Expenses for arch supports, shoe inserts designed to effect conformational changes in the foot or foot alignment, orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, readymade compression hose or support hose, or similar type devices/appliances regardless of intended use, except for therapeutic shoes (including inserts and/or modifications) for the treatment of severe diabetic foot disease; Expenses for orthotic appliances or devices, which straighten or re-shape the conformation of the head or bones of the skull or cranium through cranial banding or molding (e.g. dynamic orthotic cranioplasty or molding helmets); except when the orthotic appliance or device is used as an alternative to an internal fixation device as a result of surgery for craniosynostosis; and Expenses for devices necessary to exercise, train, or participate in sports.

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits.

Limit: 36.0 Treatment(s) per Benefit Period

Limited to 2 - 1 hour treatments per day, up to 36 treatments within a benefit period. More available beyond the initial allotment if deemed medically necessary.

Only for Breast reconstruction following a Mastectomy.

Limit: 35.0 Visit(s) per Benefit Period

Exclusions: If provided in an Inpatient setting, member must be able to actively participate in 2 rehabilitative therapies and be able to tolerate at least 3 hours per day of skilled Rehab services for at least 5 days a week. Member?s condition must be likely to significantly improve. Inpatient rehab limit is 21 days.

Combined limit for all outpatient therapy plus chiropractic.

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy plus chiropractic.

Limit: 1.0 Exam(s) per Benefit Period

Limit: 60.0 Days per Benefit Period

Dermatology virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits.

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.

Certain off-label uses of cancer drugs will be covered in accordance with state law.

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply.

Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits.