Ambetter Virtual Access Gold - Virtual PCP selection required - 34368KS0150009 Health Insurance Plan

Oral Surgical Services and Services for Accidental Injuries to Sound Natural Teeth, limited to: (1) Surgical procedures of the jaw and gums. (2) Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. (3) Removal of exostoses (bony growths) of the jaw and hard palate. (4) Treatment of fractures and dislocations of the jaw and facial bones. (5) Surgical removal of impacted teeth. (6) Treatment of Sound Natural Teeth caused by an Accidental Injury. This includes replacement of Sound Natural Teeth lost due to the Accidental Injury. (7) Intra oral dental imaging services in connection with covered oral surgery if treatment begins within 30 days. (8) General anesthesia for covered oral surgery. (9) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants and the associated fixed and/or removable prosthetic appliance when provided because of an Accidental Injury. (10) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants andthe associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions).

Allergy testing and treatment.

Outpatient self-management training and education, including medical nutrition therapy, for insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes when provided by a certified, registered or licensed health care professional with expertise in diabetes and the diabetic (1) is treated at a program approved by the American Diabetes Association; (2) is treated by a person certified by the national certification board of diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional.

Plan cover Hemodialysis.

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Limit: 3.0 Item(s) per Year

Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. 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.

Hearing Aids are a non-covered benefit. Coverage is available only for Cochlear Implants and Bone Anchored Hearing Aids.

Includes educational visits with a limit of three per year on educational visits.

Cost share is based on place of service.

Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures.

Cost share is based on place of service. Lab or blood work at Preferred Laboratories is No Charge.

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

Unlimited Virtual Visits received from Ambetter Telehealth covered at No Charge.

Unlimited Virtual Visits received from Ambetter Telehealth covered at No Charge.

Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time.

Limit: 90.0 Visit(s) per Year

These therapies include but are not limited to PT, OT, and ST. Further, '(Rehab) services are covered only if they are expected to result in significant improvement in the Insured's condition. The Company, with appropriate medical consultation, will determine whether significant improvement has occurred'. 'Speech Therapy', limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.

Unlimited Primary Care Virtual Visits received from Ambetter Telehealth covered at No Charge. Primary Virtual Care Visits are only availble for adult members (18 years of age and older).

Limited to 4 mastectomy bras per year. Limited to 1 wig per year.

Cosmetic and reconstructive are generally excluded, but excepted from this exclusion are: a. Cosmetic or reconstructive repair of an Accidental Injury.; b. Reconstructive breast surgery in connection with a Medically Necessary mastectomy that resulted from a medical illness or injury. This includes reconstructive surgery on a breast on which a mastectomy was not performed in order to produce a symmetrical appearance.; c. Repair of congenital abnormalities and hereditary complications or conditions, limited to: (1) Cleft lip or palate. (2) Birthmarks on head or neck. (3) Webbed fingers or toes. (4) Supernumerary fingers or toes.; d. Reconstructive services performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. For purposes of this provision, the term 'cosmetic' means procedures and related services performed to reshape structures of the body in order to alter the individual's appearance.

Limit: 90.0 Visit(s) per Year

Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period.

Limit: 1.0 Visit(s) per Year

Prior authorization may be required. Covered no limit.

Prior authorization may be required. Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.

Cost share is based on place of service.