Anthem Gold Pathway 1500/25% Standard - 32753MO0950023 Health Insurance Plan

Limit: 3000.0 Dollars per Episode

Limited to members through 18 years of age.

Limit: 26.0 Visit(s) per Year

Chiropractic Manipulation Therapy visits beyond the 26 visit limit require Prior Authorization from Anthem in order to be covered.

Benefits are provided only for the administration of general anesthesia and for both facility and professional charges occurring in connection with dental services, regardless of age, when prior authorization for an inpatient dental care procedure is approved by us. In addition and as required by law, benefits for the administration of general anesthesia, including facility and professional charges, are provided for the following Members; a Member through the age of four; a Member who is severely disabled and a Member who has a medical or behavioral condition that requires hospitalization or general anesthesia when dental services are provided.

Limit: 2.0 Visit(s) per Year

Emergency Room copay is waived if directly admitted to the hospital.

Non-emergency ambulance/transportation out of network is NOT covered, unless prior authorization is obtained from Anthem. Authorized out of network is limited to $50,000 per occurrence.

Limit: 1.0 Item(s) per Year

Cost share shown is for a 30 day supply.

Limit: 40.0 Visit(s) per Year

Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year. For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to Ded and or Coins. These limitations do not apply to any Autism Spectrum Disorder diagnosis. Cost share is driven by provider setting.

One hearing aid per ear every 36 months. Limit does not apply to newborn.

Limit: 100.0 Visit(s) per Year

Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year.

Limitation of Two office visits per member per Year with a Non-Network licensed provider.

Cost share shown is for a 30 day supply.

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Limit: 40.0 Visit(s) per Year

Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year. For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to Ded and or Coins. These limitations do not apply to any Autism Spectrum Disorder diagnosis. Cost share is driven by provider setting.

Cost share shown is for a 30 day supply.

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Immunizations prior to 6th birthday covered in full.

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Limit: 82.0 Visit(s) per Year

Benefit includes coverage for Private Duty Nursing in the home and Private Duty Nursing is limited to 82 visits per calendar year.

Benefits include the purchase, fitting, adjustments, repairs and replacements.

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.

Limit: 40.0 Visit(s) per Year

Rehabilitative Physical Therapy and Occupational Therapy is limited to 20 visits per year. For Covered Services you receive in the office from a Physical Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?For Covered Services you receive in the office from an Occupational Therapist, you will not have to pay an office visit Copayment or office visit Coinsurance that is higher than what you would pay for a Primary Care Physician. ?All other services are subject to Ded and or Coins. These limitations do not apply to any Autism Spectrum Disorder diagnosis. Cost share is driven by provider setting.

Limit: 1.0 Visit(s) per Year

Coverage is available if Medically Necessary Services

Limit: 150.0 Days per Year

Limited to 150 combined days per calendar year for Physical Medicine, Rehabilitation and Skilled Nursing Facility services.

You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.

Cost share shown is for a 30 day supply.

Limitation of Two office visits per member per Year with a Non-Network licensed provider.

Includes coverage for travel/lodging as approved by the plan ($10,000 per transplant). Donor search charges are limited to 10 best matched donors identified by an authorized registry.

Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures).