WellFirst by Medica Gold Copay Plus 1500X (Free Virtual Visits) - 47840MO0010001 Health Insurance Plan

Exclusions: Surgery performed to correct functional deformities of the mandible or maxilla; correction of malocclusion; orthognathic surgery; orthodontic care, periodontic care or general dental care; restoration (crowns and root canals are covered only if such treatments are the only clinically acceptable treatments for the trauma/accidental injury); tooth damage due to eating, chewing or biting.

These benefits are intended for dental treatment needed to remove, repair, replace, restore and/or reposition sound, natural teeth damaged, lost, or removed due to an injury. The term "injured" does not include conditions resulting from eating, chewing or biting. To be eligible for coverage, the services must be medically necessary while you are enrolled under this policy. The tooth must meet the definition of "sound, natural tooth".

Exclusions: Cytotoxic testing and sublingual antigens associated to allergy testing.

Exclusions: Maintenance or long-term therapy.

Exclusions: Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; Services, drugs or supplies related to abortions (For the purposes of this exclusion, an elective abortion means an abortion for any reason other than a spontaneous abortion or to prevent the death of the female upon whom the abortion is performed.); Assisted Reproductive Technology (ART) services, treatments, and/or procedures for a non-member traditional surrogate or gestational carrier, who is not covered under this policy.

47840MO0010001-01 - [20.00% Coinsurance after deductible]; 47840MO0010001-02 - [0]; 47840MO0010001-03 - [20.00% Coinsurance after deductible]; 47840MO0010002-01 - [30.00% Coinsurance after deductible]; 47840MO0010002-02 - [0]; 47840MO0010002-03 - [30.00% Coinsurance after deductible]; 47840MO0010002-04 - [30.00% Coinsurance after deductible]; 47840MO0010002-05 - [10.00% Coinsurance after deductible]; 47840MO0010002-06 - [5.00% Coinsurance after deductible]; 47840MO0010003-01 - [No Charge after deductible]; 47840MO0010003-02 - [0]; 47840MO0010003-03 - [No Charge after deductible]; 47840MO0010005-01 - [No Charge after deductible]; 47840MO0010005-02 - [0]; 47840MO0010005-03 - [No Charge after deductible]; 47840MO0010006-01 - [30.00% Coinsurance after deductible]; 47840MO0010006-02 - [0]; 47840MO0010006-03 - [30.00% Coinsurance after deductible]; 47840MO0010006-04 - [20.00% Coinsurance after deductible]; 47840MO0010006-05 - [10.00% Coinsurance after deductible]; 47840MO0010006-06 - [5.00% Coinsurance after deductible]; 47840MO0010007-01 - [No Charge after deductible]; 47840MO0010007-02 - [0]; 47840MO0010007-03 - [No Charge after deductible]; 47840MO0010008-01 - [20.00% Coinsurance after deductible]; 47840MO0010008-02 - [0]; 47840MO0010008-03 - [20.00% Coinsurance after deductible]; 47840MO0010008-04 - [20.00% Coinsurance after deductible]; 47840MO0010008-05 - [5.00% Coinsurance after deductible]; 47840MO0010008-06 - [5.00% Coinsurance after deductible]; 47840MO0010009-01 - [No Charge after deductible]; 47840MO0010009-02 - [0]; 47840MO0010009-03 - [No Charge after deductible]; 47840MO0010010-01 - [No Charge after deductible]; 47840MO0010011-01 - [20.00% Coinsurance after deductible]; 47840MO0010011-02 - [0]; 47840MO0010011-03 - [20.00% Coinsurance after deductible]; 47840MO0010012-01 - [20.00% Coinsurance after deductible]; 47840MO0010012-02 - [0]; 47840MO0010012-03 - [20.00% Coinsurance after deductible]; 47840MO0010013-01 - [20.00% Coinsurance after deductible]; 47840MO0010013-02 - [0]; 47840MO0010013-03 - [20.00% Coinsurance after deductible]; 47840MO0010013-04 - [20.00% Coinsurance after deductible]; 47840MO0010013-05 - [20.00% Coinsurance after deductible]; 47840MO0010013-06 - [20.00% Coinsurance after deductible]; 47840MO0010014-01 - [20.00% Coinsurance after deductible]; 47840MO0010014-02 - [0]; 47840MO0010014-03 - [20.00% Coinsurance after deductible]

Exclusions: Educational services, except for diabetic education and diabetic self-management training classes.

Diabetic education; diabetic self-management training classes.

Exclusions: Enteral feedings, unless they are the sole source of nutrition; however, enteral feedings of standard infant formulas, standard baby food, and regular grocery products used in blenderized formulas are excluded regardless of whether they are the sole source of nutrition. Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items. Home testing and monitoring supplies and related equipment, except as covered by our medical policy. Equipment, models or devices that have features over and above what is medically necessary (Coverage will be limited to the standard model as determined by us). Foods that are naturally low in protein. Non-prescription elastic support or anti-embolism stockings. Shoes or foot orthotics not custom-made and purchased over the counter. Any durable medical equipment or supplies used for work, athletic, or job enhancement purposes. Back-up equipment (a second piece). Replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law. Replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect. Items that can be purchased over the counter, unless coverage is required by state or federal law. Oral Nutrition: Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by law or covered under our medical policy for a specific condition. Technology devices that are not primarily and customarily used to serve a medical purpose such as desktop computers, portable multi-media players, smart phones, tablet devices and similar items are not considered durable medical equipment.

Covers medical supplies and durable medical equipment. Examples include, but are not limited to: wheelchairs, tube feeding nutrition supplies; hospital beds; oxygen and respiratory equipment; walking aids; orthopedic products; urological and ostomy supplies; orthotics and prosthetics; diabetic durable equipment and insulin infusion pumps (Insulin infusion pumps are limited to one pump per contract period and the member must use the pump for 30 days before purchasing); PKU formula and low protein modified food products for the treatment of phenylketonuria or any inherited diseases of amino acids and organic acids; Wigs (scalp prosthesis) following cancer treatment; other medical supplies as determined by us.

Exclusions: Non-emergency or non-urgent ground or air ambulance services or transportation, unless the transportation or service is listed as a covered expense or prior authorized by us. Charges for, or in connection with, any other form of travel, unless otherwise stated in this section. Member's condition does not meet medical criteria for ambulance services or transportation. Any ambulance transportation or services initiated for convenience or non-medical reasons.

Limit: 1.0 Item(s) per Year

Exclusions: Blended lenses; replacement of lost, stolen or broken lenses or frames; two pair of glasses as a substitute for bifocals; any vision services, treatment or materials not specifically listed as covered.

One pair of prescription eyeglasses per year, as follows: glass or plastic lenses; single vision, lined bifocal, lined trifocal, lenticular and progressive lenses; polycarbonate lenses; frame; scratch resistant coating; anti-reflective coating; ultraviolet protective coating. Contact lenses. Benefits for contact lenses are in lieu of your eyeglass lens benefit. If you receive contact lenses, no benefit will be available for eyeglasses until the next contract period.

Limit: 40.0 Visit(s) per Benefit Period

Exclusions: Custodial care; daycare; recreational care; respite care; vocational or life training.

Separate 20 visit(s) limit per therapy type per year for Physical and Occupational Therapy. Speech therapy is unlimited. Habilitative services and devices are those services and devices that help a person keep, learn, or improve skills and functioning for daily living. 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: 2.0 Item(s) per 3 Years

Exclusions: Batteries and chargers for hearing aids. Hearing aids that are available over the counter.

Limited to one hearing aid per ear or one set of bilateral hearing aids (both ears) and ear molds, including dispensing fees. Benefits are available per benefit period. The benefit period is 36 consecutive months from the date the benefit is first used. Repairs as medically necessary. The hearing aid must be repaired by/purchased from an authorized provider. Cochlear implants, for children and adults, including procedures for implantation and post-cochlear implant aural therapy. Bone-anchored hearing aids.

Limit: 100.0 Visit(s) per Benefit Period

Exclusions: Residential care; home care services provided by a family member or someone who resides with the member; custodial care or any service that is not required to be provided by a skilled/licensed provider.

Home care (The attending health care provider must certify that a) hospital confinement, or confinement in a skilled nursing facility, would be needed if home care was not provided; b) the member?s immediate family, or others living with the member, cannot provide the needed care and treatment without undue hardship; and c) a state licensed or Medicare certified home health agency or certified rehabilitation agency will provide or coordinate the home care.); The assessment and development of a home care plan; Physical, respiratory, occupational, behavioral health and addiction, and speech therapy; Medical supplies, drugs and medicines prescribed by a health care provider; Lab services prescribed by a health care provider; Nutritional counseling (a registered or certified dietitian must give or supervise these services); Medications administered in connection with home health care; Private duty nursing.

Exclusions: Residential care; services provided by volunteers; housekeeping or homemaking services; respite care for more than five consecutive days.

Exclusions: A drug or biologic that is not considered medically necessary. Home infusion administered by a family member or someone who resides with a family member.

Exclusions: Take home drugs and supplies dispensed by the hospital, unless a written prescription is obtained and filled at a network pharmacy; hospital stays that are extended for reasons other than medical necessity; a continued hospital stay, if the attending health care provider has documented that care could effectively be provided in a less acute care setting; separate charges for personal comfort or convenience items.

Exclusions: Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy.

A registered or certified dietitian must give or supervise these services.

Limit: 40.0 Visit(s) per Benefit Period

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Separate 20 visit(s) limit per therapy type per year for physical and occupational Therapy. Speech therapy is unlimited. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

Exclusions: Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination; birthing classes; Services, drugs or supplies related to abortions (For the purposes of this exclusion, an elective abortion means an abortion for any reason other than a spontaneous abortion or to prevent the death of the female upon whom the abortion is performed.); Assisted Reproductive Technology (ART) services, treatments, and/or procedures for a non-member traditional surrogate or gestational carrier, who is not covered under this policy.

Limit: 82.0 Visit(s) per Benefit Period

Private duty nursing services are a covered service only when given as part of the 'Home Health Care Services' benefit. Defined as individual and continuous skilled care (in contrast to part-time or intermittent care) of four or more hours; provided according to an individual plan of care, including shift care; and provided by a registered or licensed practical nurse.

Exclusions: Medical supplies and durable medical equipment for comfort, personal hygiene and convenience, regardless of medical necessity of such items; Home testing and monitoring supplies and related equipment, except as covered by our medical policy; Equipment, models or devices that have features over and above what is medically necessary (Coverage will be limited to the standard model as determined by Us); Non-prescription elastic support or anti-embolism stockings; Shoes or foot orthotics not custom-made and purchased over the counter; Any durable medical equipment or supplies used for work, athletic, or job enhancement purposes; Back-up equipment (a second piece); Replacement of durable medical equipment more frequently than every three years, unless defined by our medical policy or mandated by law; Replacement of an item that is lost, stolen, or unusable/nonfunctioning because of misuse, abuse, or neglect; Items that can be purchased over the counter, unless coverage is required by state or federal law.

Exclusions: Non-medically necessary plastic surgery. This limitation does not affect coverage provided for breast reconstruction in connection with a mastectomy. Cosmetic services and procedures, including cosmetic surgery.

Limit: 20.0 Visit(s) per Benefit Period

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Separate 20 visit(s) limit per therapy type per year for physical and occupational therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

Exclusions: Vocational rehabilitation, including work hardening programs; hearing therapy for communication delay, therapy for perceptual disorders, intellectual disability and related conditions, and other long-term special therapy, except as specifically listed under habilitative services or autism spectrum disorder section; therapy services such as recreational or educational therapy, physical fitness or exercise programs; services to enhance athletic training or performance; services or treatment received at intermediate care facilities; submaximal stress testing except for members with cardiovascular disease.

Unlimited visits for speech therapy. These therapy benefits are only for treatment of those conditions that, in the judgment of the attending health care provider, are expected to yield significant patient improvement, as determined by us. Therapists must be licensed and must not live in the patient's home or be a family member.

Limit: 1.0 Exam(s) per Benefit Period

Exclusions: Refractive eye surgery and radial keratotomy; contact lenses (except as a part of cataract surgery or therapeutic contact lenses as defined by us); refractive exams related to contact lenses; any fitting of contact lenses (except for fitting of therapeutic contact lenses as defined by us); refraction aids for low vision and instruction in their use; orthoptics (e.g., eye exercise training), except for convergence disorder; visual therapy.

One routine vision exam for children, including dilation and with refraction.

Exclusions: Podiatry services or routine foot care provided when there is no localized illness, injury, or symptoms. These include, but are not limited to: 1) the examination, treatment, or removal of all or part of corns, calluses, hypertrophy or hyperplasia of the skin or subcutaneous tissues of the feet; 2) the cutting, trimming, or other non-operative partial removal of toenails; or 3) any treatment or services in connection with any of these.

Coverage is available if Medically Necessary.

Limit: 150.0 Days per Benefit Period

Exclusions: Respite and residential care; any nursing facility services other than skilled nursing services, including intermediate care facilities and community re-entry programs; custodial care; charges for injectable medications administered in a nursing home when we do not cover the nursing home stay; tracheostomy care (if not skilled care); parenteral feeding or tube feeding care.

Limited to 150 days, combined with inpatient rehabilitative confinement, per member per benefit period.

Exclusions: Biofeedback; family counseling for non-medical reasons; wilderness and camp programs, boarding school, academy-vocational programs and group homes; halfway houses; hypnotherapy; long-term or maintenance therapy; marriage counseling; phototherapy.

Exclusions: Health services for organ and tissue transplants unless specifically covered under this policy. Organ procurement costs for a member who is donating an organ to another person. Health services for transplants involving permanent mechanical or animal organs. Transplant services that are not performed at an approved facility. Non-Covered expenses for Transplant Services and Kidney Disease Treatment: Services and supplies in connection with covered transplants when prior authorization is not obtained. Any experimental or investigational transplant. Transplants involving non-human or artificial organs.

Diagnostic procedures including diagnostic casts, diagnostic study models and bite adjustments, and medically necessary surgical or non-surgical treatment for the correction of temporomandibular joint disorders (TMJ), if the following apply: Services are provided under the accepted standards of the profession of the health care provider providing the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of this condition; the purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction; Orthognathic surgery only for the treatment of TMJ (Prior authorized may be required); craniomandibular joint services.