Elite Gold - 99723MO0090067 Health Insurance Plan

Limit: 26.0 Visit(s) per Year

Chiropractic visits beyond 26 per benefit period require Prior Authorization.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Limit: 1.0 Item(s) per Year

Covered lenses and frames each available at limit of one per year.

Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy.

Limit: 2.0 Item(s) per Year

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit.

Limit: 100.0 Visit(s) per Year

Respite Care is covered as part of hospice services only.

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Prior authorization may be required - please contact the number listed on your ID card.

Note: Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy.

Covered in accordance with ACA guidelines.

Unlimited Virtual 24/7 Care Visits received from Ambetter?s designated telehealth provider covered at No Charge, except for HSAs.

Limit: 82.0 Visit(s) per 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: 20.0 Visit(s) per Year

Limited to 20 visits per year per therapy (occupational therapy, physical therapy). No Limit for speech therapy. Limited to 36 visits per year cardiac therapy. No Limit for pulmonary therapy.

Limit: 1.0 Exam(s) per Year

Limit: 150.0 Days per Year

Prior authorization may be required - please contact the number listed on your ID card.

Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Services (excluding emergency services) rendered by an out-of-network?provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization. If you receive service from an out of network ground/water ambulance provider, you may be subject to balance billing.

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

Covered in accordance with ACA guidelines.