Limit: 3000.0 Dollars per Episode

The limit will not apply to Outpatient facility charges, anesthesia billed by a Provider other than the Physician performing the service, or to services that we are required by law to cover. Cost share is driven by provider/setting. Limited to $3,000/accident; combined In and Out of network. Benefits for Accidental Dental are based on the setting in which Covered Services are recommended.

Limit: 12.0 Visit(s) per Year

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

Limit: 1.0 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.

Limit: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Habilitation and rehabilitation visits count toward the rehabilitation limit. PT, OT and ST include an additional 20 visits each for habilitative services. Limits are combined both In and Out of Network.

Limit: 100.0 Visit(s) per Year

Cost share is based on place of service.

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).

Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.

Cost share is based on place of service.

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

Limit: 60.0 Visit(s) per Year

Cost share is driven by provider/setting. Coverage for Speech Therapy is limited to 20 visits per benefit period, Occupational Therapy is limited to 20 visits per benefit period, and Physical Therapy is limited to 20 visits per benefit period. These limits are combined in and out of network. Benefit includes an Inpatient maximum of 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network. Cardiac Rehabilitation limited to 36 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network when rendered in the home, Home Care Services limits apply.Pulmonary Rehabilitation limited to 20 visits when rendered as Physician Home Visits and Office Services or Outpatient Services, combined Network and Non-Network. When rendered in the home, Home Care Services limits apply. When rendered as part of physical therapy, the Physical Therapy limit will apply instead of the limit indicated.

Covered in accordance with ACA guidelines.

Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.

Limit: 82.0 Visit(s) per Year

Certain reconstructive services required to correct a deformity caused by disease, trauma, congenital anomalies, or previous therapeutic process are covered. Coverage includes breast reconstruction on which a mastectomy has been performed. Reconstructive services required due to prior therapeutic process are payable only if the original procedure would have been a covered service under this plan.

Limit: 40.0 Visit(s) per Year

Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.

Limit: 20.0 Visit(s) per Year

Outpatient rehabilitation limits apply. Limited to 60 combined visits per year (20 visits each for outpatient physical, speech and occupational therapy); limited to 36 visits per year for cardiac rehabilitation; limited to 20 visits per year for pulmonary rehabilitation.

Limit: 1.0 Visit(s) per Year

Coverage is limited to diabetes care only.

Limit: 90.0 Days per Year

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

Covered in accordance with ACA guidelines.

Cost share is based on place of service.