Focused Silver + Vision + Adult Dental - 77264NC0020039 Health Insurance Plan

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 30.0 Visit(s) per Year

Limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

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

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-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. $0 Insulin Options available, these are identified on your Formulary by the "#" symbol.

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

Limit: 2.0 Item(s) per 3 Years

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

Respite Care is covered as part of hospice services only.

Limit: 3.0 Treatment(s) per Lifetime

Includes certain services related to: diagnosis, correction of underlying medical conditions that cause infertility and treatment. Note: A lifetime benefit limit applies, per member, of three medical ovulation induction cycles.

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

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

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.

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.

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

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.

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

Limit: 30.0 Visit(s) per Year

Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.

Limit: 30.0 Visit(s) per Year

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Limit: 1.0 Exam(s) per Year

Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses.

Limit: 1.0 Exam(s) per Year

Limit: 60.0 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.

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. $0 Insulin Options available, these are identified on your Formulary by the "#" symbol.

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.

Covered in accordance with ACA guidelines.