AmeriHealth Caritas Next Silver Signature + No Referrals - 17414NC0010008 Health Insurance Plan

Exclusions: Excludes injury related to chewing or biting.

For surgical treatment of morbid obesity. Before pursuing bariatric surgery, a complete nutritional, behavioral, and medical evaluation must be completed, and requirements must be met. Bariatric surgery must be medically necessary to be eligible for coverage. Limited to one procedure per lifetime.

We will cover the cost of the collection or obtainment of blood or blood products from a blood donor, including the Member in the case of autologous blood donation. We will cover the cost of transfusions of blood, plasma, blood plasma expanders and other fluids injected into the bloodstream. Benefits are provided for the cost of storing a Member?s own blood only when it is stored and used for a previously scheduled procedure.

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.

Limit: 30.0 Visit(s) per Benefit Period

30 visit limits for PT and OT combined (including chiropractic).

Exclusions: Dependent children not covered for abortion.

Abortion services available for first 16 weeks of pregnancy.

Includes routine foot care.

Exclusions: Over-the-counter compression or elastic knee-high or other stocking products.

Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment.

Exclusions: Excludes services provided primarily for the convenience of travel, transportation to or from a doctor's office or dialysis center, transportation for the purpose of receiving services that are not considered covered services.

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.

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Cognitive Therapy. Group classes for pulmonary rehabilitation.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months.

Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household.

Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation.

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

Exclusions: Lab tests that are not ordered by Doctor or Other Provider

Limit: 3.0 Treatment(s) per Lifetime

Exclusions: Artificial insemination, in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and services for procurement and storage of donor semen/eggs are not covered

Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in medical policies, which are guides considered when making coverage determinations.

Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy.

Exclusions: Lab tests that are not ordered by a Doctor or Other Provider.

Exclusions: Excludes, Inpatient confinements that are primarily intended as a change of environment; Counseling with relatives of a patient.

Exclusions: Excludes counseling with relatives about a patient.

Includes biofeedback. 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.

Nutritional counseling visits are separate from the obesity-related office visits.

If a transplant is provided from a living donor to the recipient MEMBER who will receive the transplant: Benefits are provided for reasonable and necessary services related to the search for a donor. Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

Additional information can be found on the member's schedule of benefits

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

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.

AHC covers any preventive services required by federal and state laws or regulations at no charge to the member.

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 services provided by a close relative or a member of the household.

Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan.

Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.

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.

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Charges for care not provided in an office setting. Infusion therapy or chelation therapy. Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

Limit: 30.0 Visit(s) per Benefit Period

Limit: 1.0 Exam(s) per Benefit Period

Sexual Dysfunction For Treatment of Organic Disease

Limit: 60.0 Days per Benefit Period

Exclusions: Covered health services do not include custodial, domiciliary care, or long-term care admissions.

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.

Tubal Ligation is covered in full under Preventive Care.

Exclusions: Excludes, Inpatient confinements that are primarily intended as a change of environment; Counseling with relatives of a patient.

Exclusions: Excludes counseling with relatives about a patient.

Includes biofeedback. 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: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues.

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage. Reasonable costs for travel and lodging are covered and will be reimbursed for a covered transplant based on AmeriHealth guidelines available from our transplant coordinator.

Exclusions: Coverage is not provided for orthodontic braces, crowns, bridges, dentures, treatment for periodontal disease, dental root form implants, or root canals.

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.

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: Lab tests that are not ordered by a Doctor or Other Provider.