Complete Gold + Vision + Adult Dental - 75841NH0100009 Health Insurance Plan

Benefits are available for dental work that is medically necessary due to an accidental injury to sound natural teeth and gums when the course of treatment for the accidental injury is received.

Limit: 1000.0 Dollars per Year

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

Limit: 12.0 Visit(s) per Year

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 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

20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 2.0 Item(s) per Procedure

One hearing aid per ear each time a hearing aid prescription changes. Cochlear & Bone Anchored Hearing Aids are a covered benefit.

Respite Care is a covered as part of hospice services only.

Covered Services include diagnostic tests to find the cause of infertility, such as diagnostic laparoscopy, endometrial biopsy, and semen analysis. Benefits also include services to treat the underlying medical conditions that cause infertility (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

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: 20.0 Visit(s) per Year

20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis.

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: 20.0 Visit(s) per Year

20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Limit: 20.0 Visit(s) per Year

20 visits per year per therapy (occupational therapy, physical therapy and speech therapy). Cardiac rehab & pulmonary rehab have no limit. Limits do not apply when provided for a mental health/substance use disorder diagnosis.

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 eyeglasses.

Limit: 1.0 Visit(s) per Year

This Plan covers a complete eye exam with dilation, as needed.

Limit: 100.0 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.

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 under preventive care.