in network authorization out-of-network …...service type cpt code lob benefit description...

Service Type Category Benefits Summary Version 2018-09

Service Type CPT Code LOB Benefit Description Limitations Exclusions In Network Authorization Required

Out-of-Network Authorization Required

OFFICE VISITS PCP

SPECIALIST

New Patient Office Visit: 99201-99205 Established Patient Office Visit: 99211-99215 Specialist:99241-99245

Medicaid

Primary Care Physician (“PCP”): A participating Physician who typically is an internal medicine or family practice Physician and who directly provides or coordinates a range of health care services for You. Covered in full

Specialist: A Physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions Covered in full

Non-Participating Provider Services Are Not Covered.

NO Y-ALL OUT OF NETWORK

OFFICE VISITS PCP

SPECIALIST


Essential Plan 1 Non-Aliessa

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $15 Copayment Medication given in PCP Office $15 Copayment Specialist Office $25 Copayment Medication given in Specialist Office $25 Copayment

Non-Participating Provider Services Are Not Covered and Member is responsible for entire cost.


OFFICE VISITS PCP

SPECIALIST



Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $0 No Cost Sharing Medication given in PCP Office $0 No Cost Sharing Specialist Office $No Cost Sharing Medication given in Specialist Office $0 No Cost Sharing



OFFICE VISITS PCP

SPECIALIST


Essential Plan 3/4 Aliessa

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit Covered in full Medication given in PCP Office Covered in full Specialist Office Covered in full Medication given in Specialist Office Covered in full



OFFICE VISITS PCP

SPECIALIST


Child Health Plus



Non-Participating Provider Services Are Not Covered


OFFICE VISITS PCP

SPECIALIST


MetroPlus Enhanced (HARP)





OFFICE VISITS PCP

SPECIALIST


HIV Special Needs





OFFICE VISITS PCP

SPECIALIST


MetroPlus Gold

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $0 Copayment Medication given in PCP Office $0 Copayment Specialist Office $0 Copayment Medication given in Specialist Office$0 Copayment



OFFICE VISITS PCP

SPECIALIST


MetroPlus GoldCare I

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $20 Copayment Medication given in PCP Office included in PCP copay Specialist Office $40 Copayment Medication given in Specialist Office included in Specialist copay



OFFICE VISITS PCP

SPECIALIST


MetroPlus GoldCare II

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $30 Copayment Medication given in PCP Office included in PCP copay Specialist Office $50 Copayment Medication given in Specialist Office included in Specialist copay



OFFICE VISITS PCP

SPECIALIST


MedPlus Catastrophic

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit: -3 PCP office visits with $0 Copayment not subject to Deductible; -Subsequent Visits 0% Coinsurance after deductible (see limitations) Medication given in PCP Office 0% Coinsurance after deductible Specialist Office 0% Coinsurance after deductible Medication given in Specialist Office 0% Coinsurance after deductible


3 PCP office visits with $0 Copayments not subject to deductible; subsequent visits covered in full after deductible.


OFFICE VISITS PCP

SPECIALIST


BronzePlus

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit 50% Coinsurance after deductible Medication given in PCP Office 50% Coinsurance after deductible Specialist Office 50% Coinsurance after deductible Medication given in Specialist Office 50% Coinsurance after deductible



OFFICE VISITS PCP

SPECIALIST


SilverPlus

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $30 Copayment after deductible Medication given in PCP Office $30 Copayment after deductible Specialist Office $50 Copayment after deductible Medication given in Specialist Office $50 Copayment after deductible



OFFICE VISITS PCP

SPECIALIST


GoldPlus




OFFICE VISITS PCP

SPECIALIST


PlatinumPlus

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $15 Copayment Medication given in PCP Office $15 Copayment Specialist Office $35 Copayment Medication given in Specialist Office $35 Copayment



OFFICE VISITS PCP

SPECIALIST


Medicare Platinum

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $0 Copayment Medication given in PCP Office 20% of cost Part B drugs Part D based on your Deductible and Plan Specialist Office $40 Copayment Medication given in Specialist Office 20% of cost Part B drugs Part D based on your Deductible and Plan



OFFICE VISITS PCP

SPECIALIST


Medicare Advantage

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit 0% OR 20% of cost Medication given in PCP Office 20% of cost Part B drugs Part D based on your Deductible and Plan Specialist Office 0% OR 20% of cost Medication given in Specialist Office 20% of cost Part B drugs Part D based on your Deductible and Plan



OFFICE VISITS PCP

SPECIALIST


FIDA

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit $0 Copayment Medication given in PCP Office $0 Copayment Specialist Office $0 Copayment Medication given in Specialist Office $0 Copayment Home visits by medical personnel - $0 Copayment Telehealth Services - $0 Copayment



OFFICE VISITS PCP

SPECIALIST


MetroPlus Managed Long Term Care (MLTC)

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit NOT COVERED BENEFIT Medication given in PCP Office NOT COVERED BENEFIT Specialist Office NOT COVERED BENEFIT Medication given in Specialist Office NOT COVERED BENEFIT


Medical benefits, for instance, doctor's visits, emergency room care, and hospitalization are not covered by MetroPlus Managed Long Term Care.

N/A N/A

OFFICE VISITS PCP

SPECIALIST


BronzePlus HSA

Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit 50% Coinsurance after deductible Medication given in PCP Office 50% Coinsurance after deductible Specialist Office 50% Coinsurance after deductible Medication given in Specialist Office 50% Coinsurance after deductible



Primary Care Physician (“PCP”): Typically an internal medicine or family practice Physician and who directly provides or coordinates health care services

OFFICE VISITS PCP

SPECIALIST


SilverPrime

Specialist: A Physician who focuses on a specific area of medicine to treat (cardiology, geriatrics, psychiatry) PCP Office Visit: $35 Copayment (first 3 visits to PCP or Outpatient Mental Health Care not subject to Deductible) After 3 visits, $35 Copayment after Deductible. Medication given in PCP Office $35 Copayment after deductible Specialist Office $55 Copayment after deductible Medication given in Specialist Office $55 Copayment after deductible



OFFICE VISITS PCP

SPECIALIST


GoldPrime




PREVENTIVE CARE

New Patient Office Visit: 99381-99387 Established Patient Office Visit: 99391-99397 Immunization Administration: 90460,90461,90471-90474 Vision Screening: 99172,99173 , 92002,92004, 92012,92014 Hearing Screening: 92551,92552,92557 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-99404 Family Planning: contraceptives 11976,11981-11983,57170,58300,58301,S4981,S4989,S 4993A4261,A4264,A4266,G0516-

Medicaid

For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer.


No Y-ALL OUT OF NETWORK

G0518,J7296-J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586 61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091 Bone Density Measurement: 76977,77078,77080,77081,77085,G0130 Screening for Prostate Cancer: G0102-G0103,84152,84153,84154

Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer.

PREVENTIVE CARE

New Patient Office Visit: 99381-99387 Established Patient Office Visit: 99391-99397 Immunization Administration:

90460,90461,90471-90474 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-99404 Family Planning: contraceptives

11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Cervical Screenings: 88160-

88162,G0101,Q0091 Bone Density Measurement:

76977,77078,77080,7081,7085,G0130 Screening for Prostate Cancer: G0102-

G0103,84152,84153,84154


For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Adult Annual Physical Examinations : once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Adult Immunizations Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: --One (1) baseline screening mammogram for women age 35 through 39; --One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer Prenatal Care $0 Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. --Previously diagnosed as having osteoporosis or having a family history of osteoporosis --With symptoms or conditions indicative of the presence or significant risk of osteoporosis --On a prescribed drug regimen posing a significant risk of osteoporosis; --With lifestyle factors to a degree as posing a significant risk of osteoporosis; or


This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF.

Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non-therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. Covered in full not subject to deductible. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during

We do not Cover services related to the reversal of elective sterilizations. Well-Baby and Well-Child Care Are Not Covered Adult Only Plan


--With such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Prostate Screens Performed in PCP Office: $15, Specialist Office: $25

which the Contract is in effect.)

PREVENTIVE CARE


90460,90461,90471-90474 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-

99404 Cervical Screenings: 88160-88162,G0101,Q0091 Family

Planning: contraceptives 11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993A4261,A4264,A4266,G0516-G0518,J7296-


For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Adult Annual Physical Examinations : once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Adult Immunizations Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: --One (1) baseline screening mammogram for women age 35 through 39; --One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Family Planning and Reproductive Health Services FDA-approved contraceptive methods



Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non-therapeutic abortions in cases of



J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Screening for Prostate Cancer: G0102-G0103,84152,84153,84154 Bone

Density Measurement: 76977,77078,77080,77081,77085,G0130

prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. --Previously diagnosed as having osteoporosis or having a family history of osteoporosis --With symptoms or conditions indicative of the presence or significant risk of osteoporosis --On a prescribed drug regimen posing a significant risk of osteoporosis; --With lifestyle factors to a degree as posing a significant risk of osteoporosis; or --With such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer.

rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. Covered in full -not subject to deductible. . (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)

PREVENTIVE CARE


90460,90461,90471-90474 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-99404 Cervical Screenings:

88160-88162,G0101,Q0091 Family Planning: contraceptives 11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Screening for Prostate Cancer: G0102-

G0103,84152-84154 Bone Density Measurement:

76977,77078,77080,7081,7085,G0130


For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Adult Annual Physical Examinations : once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer.. Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Covered in full



Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non-therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)



PREVENTIVE CARE

New Patient Office Visit: 99381-99387 Established Patient Office Visit: 99391-99397 Immunization Administration: 90460,90461,90471-90474 Vision

Screening: 99172,99173 , 92002,92004, 92012,92014

Hearing Screening: 92551,92552,92557 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-

99404 Cervical Screenings: 88160-88162,G0101,Q0091

STI Screening:HIV-86689,86701-86703,86706,G0432,G0433,G0435;G047 5,S364586592,86780,86593,86631,86632, 87110,87270,87490,87810,87800, 87491, 87590,87591,87592,87850,87800,86592,8 6593,86780,87340,87341,G0445,99401-

99404,99411,99412 Tobacco: 99406,99407 Alcohol: 99408,99409

Preventive medicine counseling: 99401-99404,99411,99412

Nutrition:97802,87803,97804 Self Management counseling 98960-98962

Child Health Plus

For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only -Immunizations and medically necessary vaccines aimed at preventing disease including Hepatitis A and B, Gardasil, Diphtheria, Tetanus Pertussis, Measles, Mumps and Rubella, Flu, and others. -Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. -STIs screening, counseling, testing including HIV, Gonorrhea ,Chlamydia Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives American Academy of Pediatrics Bright Futures Risk Assessments including Mental Health, Obesity,Nutrition and Anticipatory Guidance and Screenings for teenagers: Bullying/Violence/Tobacco/Alcohol Use/Sexual Activity

Members with Diabetes or Asthma are entitled to Self-Management Classes for their respective diseases. Covered in full


New Patient Office Visit: 99381-99387 Established Patient Office Visit: 99391-

99397 Immunization Administration:

90460,90461,90471-90474 Vision Screening: 99172,99173 ,

92002,92004, 92012,92014

For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions.

PREVENTIVE CARE




4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586


Density Measurement:


Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer.. Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis.


76977,77078,77080,77081,77085,G0130 Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer.

PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014




4993A4261,A4264,A4266,G0516-

HIV Special Needs

For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer.


G0518,J7296-J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586


Density Measurement: 76977,77078,77080,7081,7085,G0130

Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. Vasectomies available for men. Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer.

PREVENTIVE CARE

New Patient Office Visit: 99381-99387 Established Patient Office Visit: 99391-99397 Immunization

Administration: 90460,90461,90471-90474 Vision Screening:

99172,99173 , 92002,92004, 92012,92014 Hearing Screening: 92551,92552,92557 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-99404 Family Planning: contraceptives

11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993A4261,A4264,A4266,G0516-G0518,J7296-

MetroPlus Gold

For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer, including: -Digital Tomosynthesis (3D mammogram) -Breast ultrasound -Breast MRIs




We do not Cover services related to the reversal of elective sterilizations. No Y-ALL OUT OF NETWORK

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091 Screening for Prostate Cancer: G0102-

G0103,84152,84153,84154 Bone Density Measurement:

76977,77078,77080,77081,77085,G0130

-Genetic testing for BRCA 1 or 2 gene mutations -Genetic counseling and more BRCA testing for women with positive BRCA test results. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer.

rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)

PREVENTIVE CARE

New Patient Office Visit: 99381-99387 Established Patient Office Visit: 99391-99397 Immunization

Administration: 90460,90461,90471-90474 Vision

Screening: 99172,99173 , 92002,92004, 92012,92014



Family Planning: contraceptives 11976,11981-

11983,57170,58300,58301,S4981,S4989,S


For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations i n accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care-Covered in full





4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Screening for Prostate Cancer: G0102-


76977,77078,77080,7081,7085,G0130

Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. $0 Copayment


PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014


99404 Family Planning: contraceptives 11976,11981-

11983,57170,58300,58301,S4981,S4989,S 4993A4261,A4264,A4266,G0516-

G0518,J7296-


For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care-Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA, Covered in full





J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586 61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091 Screening for Prostate Cancer: G0102-


76977,77078,77080,7081,7085,G0130

Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. $0 Copayment


PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014



Bone Density Measurement: 76977,77078,77080,77081,77085,G0130 Screening for Prostate Cancer: G0102-

G0103,84152-84154


For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or


This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”).

Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non-therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during


other physiological characteristics which pose a significant risk for osteoporosis. which the Contract is in effect.) Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Prostate Screens Performed in PCP OR Specialist office 0% Coinsurance after deductible Vasectomy 0% Coinsurance after

deductible

For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health


PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014

Hearing Screening: 92551,92552,92557 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-99404 Family Planning: contraceptives

11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586




G0103,84152,84153,84154

BronzePlus

Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations : which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA, Covered in full Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test,

This benefit is not subject to Copayments, Deductibles or Coinsurance when provided in accordance with the comprehensive guidelines supported by HRSA and items or services with an “A” or “B” rating from USPSTF, or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”).

Interruption of Pregnancy: We Cover therapeutic abortions. Covered in full not subject to Deductible

We also Cover non-therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)

Vasectomy 50% Coinsurance after


at any age for men having a prior history of prostate cancer. Prostate Screens Performed in PCP OR Specialist office 50% Coinsurance after deductible deductible

PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014



11983,57170,58300,58301,S4981,S4989,S SilverPlus

For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree




4993,A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586 61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091 Screening for Prostate Cancer: G0102-


relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA, Covered in full Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or

Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non-therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)

76977,77078,77080,7081,7085,G0130 other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Performed in PCP office $30 Copayment after deductible. Specialist office $50 copayment after deductible.

Vasectomy 50% Coinsurance after deductible

PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014


11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993,A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091


G0103,84152-84154

GoldPlus

For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care-Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Prostate Screens Performed in PCP office $25 Copayment after deductible. Specialist office $40 Copayment after deductible.




Vasectomy $100 Copayment after deductible


PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014




4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Bone Density Measurement:


G0103,84152,84153,84154

PlatinumPlus

For the purpose of promoting good health and early detection of disease.Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy o Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA, Covered in full Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Prostate Screen Performed in PCP office $15 Copayment after deductible. Specialist office $35 Copayment after deductible.






PREVENTIVE CARE

Annual Wellness Visit: G0438,G0439 Abdominal Aortic Aneurysm screening

: 76706 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-

99404 Cervical Screenings: 88160-88162,G0123,G0124,G0141-

G0148,P3000,P3001,Q0091 Cardiovasular disease screening:

80061,82465,83718,84478 Bone Density Measurement:


G0103,84152,84153,84154 Fetal Occult 81528,82270,82274,G0328

Sigmoidoscopy:45330,45331,45333, 45334,45346,45338,G0104 Colorectal

Cancer Screening:00812,45378,45380,45381,45 384,45385,45388,88305,99152,99153,G0 105,G0120,G0121,G0122,G0500,S0285

Depression screening:96161, 96127,G0444 Diabetes Screening

0403T,0488T,82947,82948,82950,82951,8 2952,83036,83037

Medicare Platinum

Welcome to Medicare” Preventive Visit only within the first 12 months you have Medicare Part B Annual Wellness Visit Your first annual wellness visit can’t take place within 12 months of your “Welcome to Medicare” preventive visit. Abdominal Aortic Aneurysm Screening one-time screening ultrasound for people at risk. Bone Density mass measurement people at risk of osteoporosis are covered every 24 months or more frequently if medically necessary Mammogram Breast cancer screening: One baseline mammogram between the ages of 35 and 39; One screening mammogram every 12 months for women age 40 and older and Clinical breast exams once every 24 months Cardiovascular disease risk reduction one visit per year with your primary care doctor to discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating well. Cardiovascular disease testing Blood tests for the detection of cardiovascular disease once every 5 years Cervical and vaginal cancer screening Pap tests and pelvic exams are covered once every 24 months If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age: one Pap test every 12 months Colorectal cancer screening For people 50 and older, the following are covered: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months Fecal occult blood test, every 12 months For people at high risk of colorectal cancer, we cover: Screening colonoscopy (or screening barium enema as an alternative) every 24 months For people not at high risk of colorectal cancer, we cover: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy Depression screening one per year. Diabetes screening fasting glucose tests Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. HIV screening One exam every 12 months (Up to three screening exams during a pregnancy) Immunizations Pneumonia vaccine, Flu shots, Hepatitis B vaccine Prostate Cancer Screening For men age 50 and older once every 12 months Digital rectal exam and Prostate Specific Antigen (PSA) test

No Coinsurance, Copayment or Deductible for preventive screenings when performed by a participating provider.


PREVENTIVE CARE

Annual Wellness Visit: G0438,G0439 Abdominal Aortic Aneurysm Screening : 76706 Mammograms: 77065-77067

Preventive Medicine counseling: 99401-99404 Cervical Screenings: 88160-88162,G0123,G0124,G0141-




G0103,84152,84153,84154 Fetal Occult 81528,82270,82274,G0328




0403T,0488T,82947,82948,82950,82951,8 2952,83036,83037

Medicare Advantage

Welcome to Medicare” Preventive Visit only within the first 12 months you have Medicare Part B Annual Wellness Visit Your first annual wellness visit can’t take place within 12 months of your “Welcome to Medicare” preventive visit. Abdominal Aortic Aneurysm Screening one-time screening ultrasound for people at risk. Bone Density mass measurement people at risk of osteoporosis are covered every 24 months or more frequently if medically necessary Mammogram Breast cancer screening: One baseline mammogram between the ages of 35 and 39; One screening mammogram every 12 months for women age 40 and older and Clinical breast exams once every 24 months Cardiovascular disease risk reduction one visit per year with your primary care doctor to discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating well. Cardiovascular disease testing Blood tests for the detection of cardiovascular disease once every 5 years Cervical and vaginal cancer screening Pap tests and pelvic exams are covered once every 24 months If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age: one Pap test every 12 months Colorectal cancer screening For people 50 and older, the following are covered: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months Fecal occult blood test, every 12 months For people at high risk of colorectal cancer, we cover: Screening colonoscopy (or screening barium enema as an alternative) every 24 months For people not at high risk of colorectal cancer, we cover: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy Depression screening one per year. Diabetes screening fasting glucose tests Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. HIV screening One exam every 12 months (Up to three screening exams during a pregnancy) Immunizations Pneumonia vaccine, Flu shots, Hepatitis B vaccine Prostate Cancer Screening For men age 50 and older once every 12 months Digital rectal exam and Prostate Specific Antigen (PSA) test



PREVENTIVE CARE

Annual Wellness Visit: G0438,G0439 Abdominal Aortic Aneurysm screening

: 76706 Screening Mammograms: 77065-77067 Preventive Medicine counseling: 99401-

99404 Cervical Screenings: 88160-88162,G0123,G0124,G0141-




G0103,84152,84153,84154 Fetal Occult 81528,82270,82274,G0328

FIDA

Welcome to Medicare” Preventive Visit only within the first 12 months you have Medicare Part B Annual Wellness Visit Your first annual wellness visit can’t take place within 12 months of your “Welcome to Medicare” preventive visit. Abdominal Aortic Aneurysm Screening one-time screening ultrasound for people at risk. Bone Density mass measurement people at risk of osteoporosis are covered every 24 months or more frequently if medically necessary Mammogram Breast cancer screening: One baseline mammogram between the ages of 35 and 39; One screening mammogram every 12 months for women age 40 and older and Clinical breast exams once every 24 months. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer,. Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Cardiovascular disease risk reduction one visit per year with your primary care doctor to discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating well. Cardiovascular disease testing Blood tests for the detection of cardiovascular disease once every 5 years Cervical and vaginal cancer screening Pap tests and pelvic exams are covered once every 24 months If you are at high risk of cervical cancer or have had an abnormal Pap test and are of childbearing age: one Pap test every 12 months Sexually transmitted infections (STIs) screening and counseling- once every 12 months or at certain times during pregnancy. Colorectal cancer screening For people 50 and older, the following are covered:






0403T,0488T,82947,82948,82950,82951,8 2952,83036,83037

Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months Fecal occult blood test, every 12 months For people at high risk of colorectal cancer, we cover: Screening colonoscopy (or screening barium enema as an alternative) every 24 months For people not at high risk of colorectal cancer, we cover: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy Depression screening one per year. Diabetes screening fasting glucose tests Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months. HIV screening One exam every 12 months (Up to three screening exams during a pregnancy) Immunizations Pneumonia vaccine, Flu shots, Hepatitis B vaccine Prostate Cancer Screening For men age 50 and older once every 12 months Digital rectal exam and Prostate Specific Antigen (PSA) test Lung Cancer Screening aged 55-77 every 12 months after having a counseling visit with ou doctor and a history of smoking a pack a day for 30 years with no signs or symptoms of lung cancer or smoke now or have quit within the last 15 years.

PREVENTIVE CARE MetroPlus Managed Long Term Care (MLTC) NOT COVERED BENEFIT


N/A N/A

PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014


11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586




G0103,84152,84153,84154

BronzePlus HSA

For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examination s: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA. Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Prostate Screens Performed in PCP OR Specialist office 50% Coinsurance after deductible




Vasectomy 50% Coinsurance after deductible

We do not Cover services related to the reversal of elective sterilizations. NO Y-ALL OUT OF NETWORK

PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014



11983,57170,58300,58301,S4981,S4989,S 4993,A4261,A4264,A4266,G0516-

G0518,J7296-J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586 61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091 Screening for Prostate Cancer: G0102-


76977,77078,77080,7081,7085,G0130

SilverPrime

For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examination s: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA, Covered in full Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Performed in PCP office $35 Copayment after deductible. Specialist office $55 copayment after deductible.






PREVENTIVE CARE


Screening: 99172,99173 , 92002,92004, 92012,92014


11976,11981-11983,57170,58300,58301,S4981,S4989,S

4993,A4261,A4264,A4266,G0516-G0518,J7296-

J7298,J7300,J7301,J7303,J7306,7307,58 340,58565,58600,58605,58611,58615,586

61,58670,58671,A4264 Cervical Screenings: 88160-88162,G0101,Q0091


G0103,84152-84154

GoldPrime

For the purpose of promoting good health and early detection of disease. Preventive services are not subject to Cost-Sharing (Copayments, or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”), or if the immunizations are recommended by the Advisory Committee on Immunization Practices (“ACIP”). Well-Baby and Well-Child Care one (1) well-child visit per calendar year, which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance, and laboratory tests ordered at the time of the visit as recommended by the American Academy of Pediatrics. Immunizations and boosters as required by ACIP. Guidelines as stated above. Ages 0-19 only Adult Annual Physical Examinations: once every calendar year, regardless of whether or not 365 days have passed since the previous physical examination visit. Vision screenings do not include refractions. Adult Immunizations in accordance with the recommendations of ACIP. Well-Woman Examinations: which consist of a routine gynecological examination, breast examination and annual Pap smear, including laboratory and diagnostic services in connection with evaluating the Pap smear. Mammograms: for the screening of breast cancer as follows: One (1) baseline screening mammogram for women age 35 through 39; One (1) baseline screening mammogram annually for women age 40 and over. Mammograms for women at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer; and for women in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer. Prenatal Care- Prenatal Care provided in accordance with the comprehensive guidelines supported by USPSTF and HRSA, Family Planning and Reproductive Health Services FDA-approved contraceptive methods prescribed by a Provider, not otherwise Covered under the Prescription Drug Coverage, counseling on use of contraceptives and related topics, and sterilization procedures for women. *vasectomies subject to Copayments or Coinsurance Bone Mineral Density Measurements or Testing Bone mineral density measurements or tests, drugs or devices shall include those covered for individuals meeting the criteria under the federal Medicare program and those in accordance with the criteria of the National Institutes of Health. Previously diagnosed as having osteoporosis or having a family history of osteoporosis; with symptoms or conditions indicative of the presence or significant risk of osteoporosis; On a prescribed drug regimen posing a significant risk of osteoporosis; with lifestyle factors to a degree as posing a significant risk of osteoporosis; or with such age, gender, and/or other physiological characteristics which pose a significant risk for osteoporosis. Screening for Prostate Cancer standard diagnostic testing including, but not limited to, a digital rectal examination and a prostate-specific antigen test, at any age for men having a prior history of prostate cancer. Prostate Screens Performed in PCP office $25 Copayment after deductible. Specialist office $40 Copayment after deductible.



Interruption of Pregnancy: We Cover therapeutic abortions. We also Cover non-therapeutic abortions in cases of rape, incest or fetal malformation. We Cover elective abortions for one (1) procedure per Member, per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.(



URGENT CARE Urgent Care Facility: POS 20 Medicaid Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. Covered in full

Non-participating Urgent Care Centers or Physicians are not covered.

NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 Essential Plan 1 Non-Aliessa

Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $25 Copayment


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 Essential Plan 2 Non-Aliessa

Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $0 No cost sharing


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 Essential Plan 3/4 Aliessa

Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. Covered in full


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 Child Health Plus Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. Covered in full


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 MetroPlus Enhanced (HARP)

Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. Covered in full


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 HIV Special Needs Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. Covered in full


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 MetroPlus Gold Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $0 Copayment

Non-participating Urgent Care Centers or Physicians are not covered. NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 MetroPlus GoldCare I Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $25 Copayment in Urgent Care Facility, $100 Copayment in Emergency Room, $20 Copayment in PCP Office


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 MetroPlus GoldCare II Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $50 Copayment in Urgent Care Facility, $150 Copayment in Emergency Room, $30 Copayment in PCP Office


URGENT CARE Urgent Care Facility: POS 20 MedPlus Catastrophic

Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. 0% Coinsurance after deductible


URGENT CARE Urgent Care Facility: POS 20 BronzePlus Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. 50% Coinsurance after deductible


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 SilverPlus Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $70 Copayment after deductible


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 GoldPlus Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $60 Copayment after deductible


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 PlatinumPlus Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $55 Copayment


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 Medicare Platinum Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $0 Copayment


NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 Medicare Advantage Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. 0% OR 20% of Cost (up to $65)


If admitted to the hospital within 3 days, You do not have to pay your share of the cost for urgently needed services.

NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 FIDA Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $0 Copayment


NO Not Covered

URGENT CARE N/A MetroPlus Managed Long Term Care (MLTC)

Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. NOT COVERED BENEFIT


N/A N/A

URGENT CARE Urgent Care Facility: POS 20 BronzePlus HSA Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. 50% Coinsurance after deductible

NO Not Covered

URGENT CARE SilverPrime Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $70 Copayment after deductible

NO Not Covered

URGENT CARE Urgent Care Facility: POS 20 GoldPrime Urgent Care is medical care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require Emergency Department Care. Urgent Care is typically available after normal business hours, including evenings and weekends. $60 Copayment after deductible

NO Not Covered

EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Medicaid

ED Services, in participating and non-participating facilities, are covered for medical or behavioral (i.e. psychiatric) conditions.

The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy Covered in full

We do not Cover follow-up care or routine care provided in a Hospital emergency department. NO NO

EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Essential Plan 1

Non-Aliessa


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy $75 Copayment


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Essential Plan 2

Non-Aliessa


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy $0 No cost sharing


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Essential Plan 3/4

Aliessa


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy Covered in Full


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Child Health Plus




EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 MetroPlus Enhanced

(HARP)




EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 HIV Special Needs




EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 MetroPlus Gold




EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 MetroPlus GoldCare I




EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 MetroPlus GoldCare II




EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 MedPlus

Catastrophic


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy 0% Coinsurance after deductible

Coinsurance payment is waived if the member is admitted directly from the Emergency Department.

Non-Participating Provider Emergency Department Services 0% Coinsurance after Deductible


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 BronzePlus






EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 SilverPlus


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy $250 Copayment after deductible


Non-Participating Provider Emergency Department Services $150 Copayment after Deductible


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 GoldPlus






EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 PlatinumPlus






EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Medicare Platinum



If admitted to the hospital within 3 days, member does not have to pay the share of the cost for emergency care. Inpatient hospital cost rates apply.


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 Medicare Advantage


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy 0% OR 20% Cost (up to $80)

If admitted to the hospital within 24 hours, member does not have to pay the share of the cost for emergency care. Inpatient hospital cost rates apply.


EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 FIDA



If admitted to the hospital within 24 hours, member does not have to pay the share of the cost for emergency care. Inpatient hospital cost rates apply.


EMERGENCY DEPARTMENT (ED) SERVICES N/A MetroPlus Managed

Long Term Care (MLTC)


The onset of these conditions can be sudden, manifesting itself by symptoms of sufficient severity, including severe pain that a prudent layperson could reasonably expect the absence of medical attention to result in: - Placing the health of the person afflicted with such condition in serious jeopardy or in the case of a behavioral condition, placing the health of such person or others in jeopardy - Placing the health of the person afflicted with such condition in serious jeopardy NOT COVERED BENEFIT


N/A NO

EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 BronzePlus HSA






EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 SilverPrime





NO NO

EMERGENCY DEPARTMENT (ED) SERVICES ED visit: 99281-99285 GoldPrime






OBSERVATION

Facility Observation Visits- Initial and Discharge: 99217-99220 Subsequent Observation Visits : 99224-99226 Observation/Inpatient Visits-Admitted/Discharged on the Same Date: 99234-99236

Medicaid Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. Covered in full

Non-Participating Providers Services Are Not Covered.

This fee is waived if observation stay is associated with direct transfer from outpatient surgical setting.


OBSERVATION



Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $75 Copayment.

Non-Participating Providers Services Are Not Covered and member responsible for entire cost.



OBSERVATION



Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $0 Copayment




OBSERVATION



Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. Covered in full




OBSERVATION


Child Health Plus Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. Covered in full




OBSERVATION



Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. Covered in full




OBSERVATION


HIV Special Needs Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. Covered in full




OBSERVATION


MetroPlus Gold Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $0 Copayment




OBSERVATION


MetroPlus GoldCare I Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $100 Copayment




OBSERVATION


MetroPlus GoldCare II Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $150 Copayment




OBSERVATION



Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. 0% Coinsurance after deductible




OBSERVATION


BronzePlus Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. 50% Coinsurance after deductible




OBSERVATION


SilverPlus Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $250 Copayment after deductible




OBSERVATION


GoldPlus Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $150 Copayment after deductible




OBSERVATION


PlatinumPlus Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $100 Copayment




OBSERVATION


Medicare Platinum Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. 20% of Cost




OBSERVATION


Medicare Advantage Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. 0% OR 20% Cost




OBSERVATION


FIDA Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $0 Copayment




OBSERVATION N/A MetroPlus Managed Long Term Care (MLTC)

Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. NOT COVERED BENEFIT


N/A N/A

OBSERVATION


BronzePlus HSA Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. 50% Coinsurance after deductible




OBSERVATION


SilverPrime Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $250 Copayment after deductible




OBSERVATION


GoldPrime Observation services are Hospital outpatient services provided to help a Physician decide whether to admit or discharge You. These services include use of a bed and periodic monitoring by nursing or other licensed staff. $150 Copayment after deductible




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Medicaid Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Covered in full


YES **COSMETIC**BOTOX**

**ERECTILE DYSFUNCTION** ONLY

Y- ALL OUT OF NETWORK

AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Essential Plan 1 Non-Aliessa

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Ambulatory Surgery Center $50 Copayment Outpatient Hospital $50 Copayment

Non-Participating Provider Services Are Not Covered and member is responsible for entire cost.


ONLY Y- ALL OUT OF NETWORK

AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Essential Plan 2 Non-Aliessa





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Essential Plan 3/4 Aliessa





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Child Health Plus Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Covered in full




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 MetroPlus Enhanced (HARP)

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Covered in full





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 HIV Special Needs Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Covered in full





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 MetroPlus Gold





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 MetroPlus GoldCare I Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” $100 copay (same in OP facility or physician office)




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 MetroPlus GoldCare II Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” $200 copay (same in OP facility or physician office)




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 MedPlus Catastrophic

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Ambulatory Surgery Center 0% Coinsurance after deductible Outpatient Hospital 0% Coinsurance after deductible




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 BronzePlus





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 SilverPlus

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Ambulatory Surgery Center $100 Copayment after deductible Outpatient Hospital $100 Copayment after deductible




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 GoldPlus





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 PlatinumPlus





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Medicare Platinum

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Ambulatory Surgery Center $50 Copayment Outpatient Hospital 20% of Cost




AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 Medicare Advantage

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Ambulatory Surgery Center 0% OR 20% of Cost Outpatient Hospital 0% OR 20% of Cost





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 FIDA






AMBULATORY SURGERY N/A MetroPlus Managed Long Term Care (MLTC)

Outpatient surgery , including services provided at hospital outpatient facilities and ambulatory surgical centers. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Ambulatory Surgery Center NOT COVERED BENEFIT Outpatient Hospital NOT COVERED BENEFIT


N/A N/A

AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 BronzePlus HSA





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 SilverPrime





AMBULATORY SURGERY Ambulatory Surgical Center : POS 24 GoldPrime





ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Medicaid

Anesthesia services that are required for any surgical procedure both the inpatient and the outpatient setting are covered (this includes oral surgery procedures). Covered in full

Non-Participating Provider Services Are Not Covered. NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Essential Plan 1

Non-Aliessa



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Essential Plan 2

Non-Aliessa



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Essential Plan 3/4

Aliessa



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Child Health Plus



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 MetroPlus Enhanced

(HARP)



ANESTHESIA SERVICES ALL SETTINGS 01000-01999 HIV Special Needs



ANESTHESIA SERVICES ALL SETTINGS 01000-01999 MetroPlus Gold

Anesthesia services that are required for any surgical procedure both the inpatient and the outpatient setting are covered (this includes oral surgery procedures). $0 Copayment


NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 MetroPlus GoldCare I

Anesthesia services that are required for any surgical procedure both the inpatient and the outpatient setting are covered (this includes oral surgery procedures). Included in inpatient hospital and ambulatory surgery copay


NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 MetroPlus GoldCare II

Anesthesia services that are required for any surgical procedure both the inpatient and the outpatient setting are covered (this includes oral surgery procedures). Included in inpatient hospital and ambulatory surgery copay


NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 MedPlus

Catastrophic

Anesthesia services that are required for any surgical procedure both the inpatient and the outpatient setting are covered (this includes oral surgery procedures). 0% Coinsurance after deductible


NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 BronzePlus



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 SilverPlus



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 GoldPlus



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 PlatinumPlus



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Medicare Platinum



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 Medicare Advantage



ANESTHESIA SERVICES ALL SETTINGS 01000-01999 FIDA



ANESTHESIA SERVICES ALL SETTINGS N/A MetroPlus Managed


Anesthesia services that are required for any surgical procedure both the inpatient and the outpatient setting are covered (this includes oral surgery procedures). NOT COVERED BENEFIT


NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 BronzePlus HSA



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 SilverPrime



NO N/A

ANESTHESIA SERVICES ALL SETTINGS 01000-01999 GoldPrime



NO N/A

OUTPATIENT PROFESSIONAL SERVICES

Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450, 96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168 Speech Therapy- 92507, 92508 Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479

Medicaid

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office Covered in full Performed in Specialist Office Covered in full Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office Covered in full Performed in Outpatient Hospital Covered in full Chemotherapy Performed in a PCP Office Covered in full Performed in a Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. See Limitation Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Covered in full Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office. Covered in full Hospice Care only when Physician has certified that You have twelve (12) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. Covered in full Consumer Directed Personal Assistance Services (CDPAS)/Personal Care (PCS) Must be medically needed and arranged by MetroPlus Enhanced. Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. Covered in full


Habilitation/Rehabilitation Services : 40 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per calendar year. Children 0-20 years of age and /or members with developmental disabilities or traumatic brain injury may be eligible for additional visits. Authorization required.

Chiropractic Services is not a covered service for adults under Medicaid Managed Care. However, chiropractic services are covered for children under the age of 21 as per Early Periodic Screening Diagnosis and Treatment (EPSDT) program requirements for physical and mental disabilities and conditions, when

Hospice Care: Not Covered: funeral arrangements; pastoral, financial, or legal counseling; homemaker, caretaker, or respite care.

Y‐PT/OT/ST after first 20 visits for each discipline

Y‐CHIROPRATIC

Y‐PRENATAL/GENETIC TESTING

Y‐PCS

Y‐ CARDIAC REHABILITATION

Y-ALL OUT OF NETWORK

ordered by a physician. Authorization required.


Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450, 96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-


Allergy Testing/Treatment : Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $15 Copayment Performed in Specialist Office $25 Copayment Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 5% Coinsurance Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $25 Copayment Performed in Outpatient Hospital $25 Copayment Chemotherapy Performed in a PCP Office $15 Copayment Performed in a Specialist Office $15 Copayment Performed as Outpatient Hospital Services $15 Copayment Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion,

Non-Participating Provider Services Are Not Covered and member responsible for all costs.

Habilitation/Rehabilitation Services: 60 visits combined per condition per Plan Yea. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH Y-ALL OUT OF NETWORK

62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168 Speech Therapy- 92507, 92508 Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479

misalignment or subluxation of or in the vertebral column. $25 Copayment Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $15 Copayment Performed in Specialist Office, Freestanding Laboratory Facility, or Outpatient Hospital $25 Copayment Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits combined per condition per Plan Year. $15 Copayment (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $15 Copayment

Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury.





Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $0 Copayment Performed in Specialist Office $0 Copayment Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $0 Copayment Performed in Outpatient Hospital $0 Copayment Chemotherapy Performed in a PCP Office $0 Copayment Performed in a Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $0 Copayment Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $0 Copayment Performed in Specialist Office $0 Copayment Habilitation/Rehabilitation Services c onsisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 combined visits per condition per Plan Year. $0 Copayment (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $0 Copayment


Habilitation/Rehabilitation Services: 60 combined visits per condition per Plan Year. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury.


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH






Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office Covered in full Performed in Specialist Office Covered in full Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office Covered in full Performed in Outpatient Hospital Covered in full Chemotherapy Performed in a PCP Office Covered in full Performed in a Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. Covered in full Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office Covered in full Performed in Specialist Office, Freestanding Laboratory or Outpatient Hospital Covered in full Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office or up to 60 visits combined per condition per Plan Year. Covered in full. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. Covered in full


Habilitation/Rehabilitation Services: 60 visits per condition per Plan Year. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. The request may be made after the date of the service and can be approved if the beneficiary has not already been authorized for 20 visits. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH



covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been


Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450, 96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-

Child Health Plus

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office Covered in full Performed in Specialist Office Covered in full Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office Covered in full Performed in Outpatient Hospital Covered in full Chemotherapy Performed in a PCP Office Covered in full Performed in a Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion,


Physical and Occupational Therapy The therapy must be skilled therapy. Short-term which means not to exceed 40 visits within one calendar year.

Speech Therapy Services required for a condition amenable to significant clinical improvement within a two


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH

Y‐PRENATAL/GENETIC TESTING Y-ALL OUT OF NETWORK

62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168 Speech Therapy- 92507, 92508 Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479-

misalignment or subluxation of or in the vertebral column. Not covered. See Limitation Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Covered in full Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office. Short Term means not to exceed 40 visits within 1 calendar year. Covered in full Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. Covered in full

month period beginning with the first day of therapy, when performed by an audiologist, language pathologist, a speech therapist and/or otolaryngologist.

Chiropractic Services are not covered





Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office Covered in full Performed in Specialist Office Covered in full Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office Covered in full Performed in Outpatient Hospital Covered in full Chemotherapy Performed in a PCP Office Covered in full Performed in a Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. See Limitation Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Covered in full Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office. Covered in full Hospice Care only when Physician has certified that You have twelve (12) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. Covered in full Consumer Directed Personal Assistance Services (CDPAS)/Personal Care (PCS) Must be medically needed and arranged by MetroPlus Enhanced. Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. Covered in full


Habilitation/Rehabilitation Services : 40 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per therapy per calendar year, unless you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. Authorization required.

Chiropractic Services is not a covered service for adults under Medicaid Managed Care. However, chiropractic services are covered for children under the age of 21 as per Early Periodic Screening Diagnosis and Treatment (EPSDT) program requirements for physical and mental disabilities and conditions, when ordered by a physician.



Y‐CHIROPRATIC


Y‐PCS




Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450, 96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168

HIV Special Needs

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office Covered in full Performed in Specialist Office Covered in full Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office Covered in full Performed in Outpatient Hospital Covered in full Chemotherapy Performed in a PCP Office Covered in full Performed in a Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. See Limitation Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Covered in full Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office. Covered in full Hospice Care only when Physician has certified that You have twelve (12) months or less to live pursuant to Article 40 of the New York Public Health Law.


Habilitation/Rehabilitation Services : 40 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per therapy per calendar year. Children 0-20 years of age and /or members with developmental disabilities or traumatic brain injury may be eligible for additional visits. Authorization required.

Chiropractic Services is not a covered service for adults under Medicaid Managed Care. However, chiropractic services are covered for children under the age of 21 as per Early Periodic Screening Diagnosis and Treatment



Y‐CHIROPRATIC


Y‐PCS



Speech Therapy- 92507, 92508 Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479 CDPAS-

Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. Covered in full Consumer Directed Personal Assistance Services (CDPAS)/Personal Care (PCS) Must be medically needed and arranged by MetroPlus Enhanced. Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. Covered in full

(EPSDT) program requirements for physical and mental disabilities and conditions, when ordered by a physician. Authorization required.



MetroPlus Gold

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $0Copayment Performed in Specialist Office $0 Copayment Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Covered in full Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $0Copayment Performed in Outpatient Hospital $0 Copayment Chemotherapy Performed in a PCP Office $0 Copayment Performed in a Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $0 Copayment Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $0 Copayment Performed in Specialist Office $0 Copayment Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 20 visits per Plan Year, combined therapies. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) $0 Copayment Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $0 Copayment


Habilitation/Rehabilitation Services: 20 visits per Plan Year. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury.

Habilitation/Rehabilitation Services In no event will the therapy continue beyond 365 days after such event.


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH







Allergy Testing/Treatment : Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $20 Copayment Performed in Specialist Office $40 Copayment Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Included in inpatient hospital copay Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $40 Copayment Performed in Outpatient Hospital $40 Copayment Chemotherapy Performed in a PCP Office $20 Copayment Performed in a Specialist Office $40 Copayment Performed as Outpatient Hospital Services $40 Copayment Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $40 Copayment Diagnostic Testing/Laboratory Procedures : services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed In Physician Office -included in PCP or Specialist copay Performed as Outpatient Hospital Services , $100 Copayment Performed in a Freestanding Laboratory, $40 Copayment Rehabilitation/Habilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 90 visits per Plan year, combined therapies. (Plan Year: The 12-month period beginning on the effective date of the Certificate or any anniversary date thereafter, during which the Certificate is in effect.) Outpatient Rehabilitation: $40 Copayment Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $0 Copayment, 210 days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Acupuncture - NOT COVERED BENEFIT


Rehabilitation Services: 90 visits per Plan Year combined therapies. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.) Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury. Habilitation Services Not Covered

Rehabilitation Services In no event will the therapy continue beyond 365 days after such event.


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH

Y‐GENETIC TESTING

Y‐ Cardiac Rehabilitation





Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $30 Copayment Performed in Specialist Office $50 Copayment Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. Included in inpatient hospital copay Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $50 Copayment Performed in Outpatient Hospital $50 Copayment Chemotherapy Performed in a PCP Office $30 Copayment Performed in a Specialist Office $50 Copayment Performed as Outpatient Hospital Services $50 Copayment Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $50 Copayment Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed In Physician Office -included in PCP or Specialist copay Performed as Outpatient Hospital Services , $150 Copayment Performed in a Freestanding Laboratory, $50 Copayment Rehabilitation/Habilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 90 visits per Plan year, combined therapies. (Plan Year: The 12-month period beginning on the effective date of the Certificate or any anniversary date thereafter, during which the Certificate is in effect.) Outpatient Rehabilitation: $50 Copayment


Rehabilitation Services: 90 visits per Plan Year combined therapies. (Plan Year: The 12-month period beginning on the effective date of the Certificate or any anniversary date thereafter, during which the Certificate is in effect.) The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a

Rehabilitation Services In no event will the therapy continue beyond 365 days after such event.


Y‐CHIROPRATIC

Y‐PT/OT/SPEECH




Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $0 Copayment, 210 days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Certificate or any anniversary date thereafter, during which the Certificate is in effect.) Acupuncture - NOT COVERED BENEFIT

covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury. Habilitation Services Not Covered




Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office 0% Coinsurance after deductible Performed in Specialist Office 0% Coinsurance after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 0% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office 0% Coinsurance after deductible Performed in Outpatient Hospital 0% Coinsurance after deductible Chemotherapy Performed in a PCP Office 0% Coinsurance after deductible Performed in a Specialist Office 0% Coinsurance after deductible Performed as Outpatient Hospital Services 0% Coinsurance after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. 0% Coinsurance after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office 0% Coinsurance after deductible Performed in Specialist Office 0% Coinsurance after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.) 0% Coinsurance after deductible Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days per Plan Year by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. 0% Coinsurance after deductible (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)


Habilitation/Rehabilitation Services: 60 visits per condition per calendar Year. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a



Y‐CHIROPRATIC

Y‐PT/OT/SPEECH




Physician; and You have been hospitalized or have undergone surgery for such illness or injury.



BronzePlus

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office 50% Coinsurance after deductible Performed in Specialist Office 50% Coinsurance after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 50% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office 50% Coinsurance after deductible Performed in Outpatient Hospital 50% Coinsurance after deductible Chemotherapy Performed in a PCP Office 50% Coinsurance after deductible Performed in a Specialist Office 50% Coinsurance after deductible Performed as Outpatient Hospital Services 50% Coinsurance after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. 50% Coinsurance after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office 50% Coinsurance after deductible Performed in Specialist Office 50% Coinsurance after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.) 50% Coinsurance after deductible Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. 50% Coinsurance after deductible


Habilitation/Rehabilitation Services: 60 visits per condition per calendar Year. The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury.



Y‐CHIROPRATIC

Y‐PT/OT/SPEECH






SilverPlus

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $30 Copayment after deductible Performed in Specialist Office $50 Copayment after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 30% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $30 Copayment after deductible Performed in Outpatient Hospital $30 Copayment after deductible Chemotherapy Performed in a PCP Office $30 Copayment after deductible Performed in a Specialist Office $30 Copayment after deductible Performed as Outpatient Hospital Services $30 Copayment after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $50 Copayment after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $30 Copayment after deductible Performed in Specialist Office, Freestanding Laboratory Facility or Outpatient Hospital $50 Copayment after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year, combined therapies. $30 Copayment after deductible (Plan Year: A calendar year ending on December 31 of each year.) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $30 Copayment after deductible





Y‐CHIROPRATIC

Y‐PT/OT/SPEECH







GoldPlus

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $25 Copayment after deductible Performed in Specialist Office $40 Copayment after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 20% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $25 Copayment after deductible Performed in Outpatient Hospital $25 Copayment after deductible Chemotherapy Performed in a PCP Office $25 Copayment after deductible Performed in a Specialist Office $25 Copayment after deductible Performed as Outpatient Hospital Services $25 Copayment after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $40 Copayment after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $25 Copayment after deductible Performed in Specialist Office, Freestanding Laboratory or Outpatient Hospital $40 Copayment after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits, combined, per condition per calendar Year. $30 Copayment after deductible Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family.$25 Copayment after deductible





Y‐CHIROPRATIC

Y‐PT/OT/SPEECH






PlatinumPlus

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $15 Copayment Performed in Specialist Office $35 Copayment Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 10% Coinsurance Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $15 Copayment Performed in Outpatient Hospital $15 Copayment Chemotherapy Performed in a PCP Office $15 Copayment Performed in a Specialist Office $15 Copayment Performed as Outpatient Hospital Services $15 Copayment Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $35 Copayment Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $15 Copayment Performed in Specialist Office, Freestanding Laboratory Facility or Outpatient Hospital $35 Copayment Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year, combined therapies. $25 Copayment (Plan Year: A calendar year ending on December 31 of each year.) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family.$15 Copayment

Non-Participating Provider Services Are Not Covered and member responsible for all cost.




Y‐CHIROPRATIC

Y‐PT/OT/SPEECH






Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450, 96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168

Medicare Platinum

Autologous Blood Banking including storage and administration Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. 20% of Cost Cardiac Rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s referral. $0 Copayment Chemotherapy Performed in a PCP Office $15 Copayment after deductible Performed in a Specialist Office $15 Copayment after deductible Performed as Outpatient Hospital Services $15 Copayment after deductible Chiropractic Services Manual manipulation of the spine to correct a subluxation.$20 Copayment Diagnostic Testing/Laboratory Services: 20% of Cost Hospice Care a Medicare certified hospice program when your doctor and the hospice medical director have given your a terminal prognosis certifying you have 6 months or less to live. This includes drugs to control pain, short-term respite and home care. Covered by Medicare NOT MetroPlus Podiatry Services: Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions. $30 Copayment Pulmonary Rehabilitation Members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and a referral from the doctor treating the chronic respiratory disease. $0 Copayment Rehabilitation: include physical therapy, occupational therapy, and speech language therapy services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs). $25 Copayment


Cardiac rehabilitation maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks.

Injectable chemotherapeutic drugs are covered when administered in an MD office and billed as part of an MD visit. Experimental or investigative drugs and protocols are excluded unless authorized by MetroPlus Utilization Management.

Hospice Care: Not Covered: funeral arrangements; pastoral, financial, or legal counseling; homemaker, caretaker.

Y‐PT/OT/SPEECH > 10 visits




Speech Therapy- 92507, 92508


Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450, 96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168 Speech Therapy- 92507, 92508 Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479 CDPAS- 99341-99350,99500-99602

Medicare Advantage

Autologous Blood Banking including storage and administration Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. 0% OR 20% of Cost Cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s referral. 0% OR 20% of Cost Chemotherapy Performed in a PCP Office 0% OR 20% of Cost Performed in a Specialist Office 0% OR 20% of Cost Performed as Outpatient Hospital Services 0% OR 20% of Cost Chiropractic Services Manual manipulation of the spine to correct a subluxation.0% OR 20% of Cost Diagnostic Testing/Laboratory Services: 0% OR 20% of Cost Hearing Services Exam to diagnose and treat balance issues Fully Covers Hospice Care a Medicare certified hospice program when your doctor and the hospice medical director have given your a terminal prognosis certifying you have 6 months or less to live. This includes drugs to control pain, short-term respite and home care. Covered by Medicare NOT MetroPlus Podiatry Services: Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions. 0% or 20% of Cost Routine Foot care - Fully Covered Pulmonary rehabilitation Members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and a referral from the doctor treating the chronic respiratory disease. 0% OR 20% of Cost Rehabilitation: include physical therapy, occupational therapy, and speech language therapy services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs). 0% OR 20% of Cost Consumer Directed Personal Assistance Services (CDPAS)/Personal Care (PCS) Must be medically needed and arranged by MetroPlus Enhanced. Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. Covered by Fee for Service Medicaid





Y‐PT/OT/SPEECH > 10 visits




Allergy Test: 95004-95071 Autologous Blood Banking: 86850-86999 Cardiac/Pulmonary Rehabilitation: 93797-93799 ,G0422, G0423, G0424 Chemotherapy Administration: 96401-96417, 96420-96425, 96440-96450,

Autologous Blood Banking including storage and administration Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else.$0 Copayment Cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s referral. $0 Copayment Chemotherapy Performed in a PCP Office $0 Copayment Performed in a Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Chiropractic Services Manual manipulation of the spine to correct a subluxation.$0 Copayment Diagnostic Testing/Laboratory Services : $0 Copayment Hospice Care a Medicare certified hospice program when your doctor and the hospice medical director have given your a terminal prognosis certifying you have 6 months or less to live. This includes drugs to control pain, short-term respite and home care. Covered by Medicare NOT MetroPlus Podiatry Services: Foot exams and treatment if you have diabetes related nerve damage and/or meet certain medical conditions affecting lower limbs,

Outpatient rehabilitation services: OT, PT, and ST services are limited to 40 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per calendar year. year except for individuals with intellectual disabilities, individuals with traumatic brain injury, and individuals under age 21.


96542-96549 Chiropractic Manipulation: 98940-98943 Diagnostic Testing/Laboratory procedure 91110-91299,94010-94799,86355-86593,95921-95943,62270-62272 ,81000-81099,85055-85705,84681-84999,91030-91040,82943-82962,80305-80307 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168 Speech Therapy- 92507, 92508 Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479

FIDA

including diagnosis and medical or surgical treatment of injuries and diseases of the foot (such as hammer toe or heel spurs). $0 Copayment Pulmonary rehabilitation Members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and a referral from the doctor treating the chronic respiratory disease. $0 Copayment Rehabilitation: include physical therapy, occupational therapy, and speech language therapy services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs). Limited to twenty (20) visits per therapy per calendar year except for individuals with intellectual disabilities, individuals with traumatic brain injury, and individuals under age 21.$0 Copayment Consumer Directed Personal Assistance Services (CDPAS)/Personal Care (PCS) Must be medically needed and arranged by MetroPlus Enhanced. Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. Covered in full Home Maintenance Services - includes household chores and services that are required to maintain an individual’s home environment in a sanitary, safe, and viable manner. Moving assistance - from inadequate or unsafe housing to an environment which more adequately meets the Participant’s health and welfare needs and reduces the risk of unwanted nursing facility placement Independent Living Skills and Training (ILST) - to improve or maintain the ability of the Participant to live as independently as possible in the community. ILST may be provided in the Participant’s residence and in the community. Medical Nutrition Therapy - for Participants with diabetes or kidney disease without dialysis. It is also for after a kidney transplant when referred by your





Y‐PT/OT/SPEECH




provider. three hours of one-on-one counseling services during your first year that you get medical nutrition therapy services under Medicare, and two hours of one-on-one counseling services each year after that. More hours may be approved by the IDT. Smoking and tobacco cessation - two counseling quit attempts in a 12 month period as a preventive service., and for pregnant women and women up to six months after birth.


Respiratory Therapy- 94014-94799 Podiatry- G0127,11055-11057,11719-11721 Physical Therapy- 97161-97164 Occupational Therapy- 97165-97168 Speech Therapy- 92507, 92508 Hospice Care- 99377-99378,T2042-T2046,G9474,G9477-G9479 Consumer Directed Personal


Respiratory Therapy Performed in Specialist Office Covered in full Performed in Outpatient Hospital Covered in full

Podiatry: services are covered for members with a diagnosis of Diabetes and conditions of the feet related to that diagnosis. Performed in a PCP Office Covered in full Performed in a Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full

Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office. Covered in full

Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. Covered in full


Habilitation/Rehabilitation Services : 20 physical therapy visits, 20 occupational therapy visits, and 20 speech therapy visits per enrollee per calendar year, except for children under age 21 and the developmentally disabled. An MLTC Plan


Y-ALL PCS FOR MLTC

Y-PT/OT/SPEECH

Y-ALL SERVICES ARE COORDINATED


Assistance 99341-99350,99500-99602 Consumer Directed Personal Assistance Services (CDPAS)/Personal Care (PCS) Must be medically needed and arranged by MetroPlus Enhanced. Help with bathing, dressing and feeding, help preparing meals and housekeeping, plus home health aide and nursing. Covered in full

may authorize additional visits



BronzePlus HSA

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office 50% Coinsurance after deductible Performed in Specialist Office 50% Coinsurance after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 50% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office 50% Coinsurance after deductible Performed in Outpatient Hospital 50% Coinsurance after deductible Chemotherapy Performed in a PCP Office 50% Coinsurance after deductible Performed in a Specialist Office 50% Coinsurance after deductible Performed as Outpatient Hospital Services 50% Coinsurance after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. 50% Coinsurance after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office 50% Coinsurance after deductible Performed in Specialist Office 50% Coinsurance after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year, combined therapies. (Plan Year: A calendar year ending on December 31 of each year.) 50% Coinsurance after deductible Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. 50% Coinsurance after deductible





Y‐CHIROPRATIC

Y‐PT/OT/SPEECH


Y‐ Cardiac Rehabilitation




SilverPrime

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $35 Copayment after deductible Performed in Specialist Office $55 Copayment after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 30% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $35 Copayment after deductible Performed in Outpatient Hospital $35 Copayment after deductible Chemotherapy Performed in a PCP Office $35 Copayment after deductible Performed in a Specialist Office $35 Copayment after deductible Performed as Outpatient Hospital Services $35 Copayment after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $55 Copayment after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $35 Copayment after deductible Performed in Specialist Office, Freestanding Laboratory Facility or Outpatient Hospital $55 Copayment after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year, combined therapies . $35 Copayment after deductible. (Plan Year: A calendar year ending on December 31 of each year.) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family. $35 Copayment after deductible





Y‐CHIROPRATIC

Y‐PT/OT/SPEECH







GoldPrime

Allergy Testing/Treatment: Testing and evaluations including injections, and scratch and prick tests to determine the existence of an allergy. Allergy treatment, including desensitization treatments, routine allergy injections and serums. Performed in PCP Office $25 Copayment after deductible Performed in Specialist Office $40 Copayment after deductible Autologous Blood Banking only when they are being provided in connection with a scheduled, covered Inpatient procedure for the treatment of a disease or injury. In such instances, Covered for period that is appropriate for having the blood available when it is needed. 20% Coinsurance after deductible Cardiac/Pulmonary Rehabilitation Performed in Specialist Office $25 Copayment after deductible Performed in Outpatient Hospital $25 Copayment after deductible Chemotherapy Performed in a PCP Office $25 Copayment after deductible Performed in a Specialist Office $25 Copayment after deductible Performed as Outpatient Hospital Services $25 Copayment after deductible Chiropractic Services only covered for detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. $40 Copayment after deductible Diagnostic Testing/Laboratory Procedures: services and materials including: laboratory tests, fluoroscopy, electrocardiograms and electroencephalograms. Performed in PCP Office $25 Copayment after deductible Performed in Specialist Office, Freestanding Laboratory or Outpatient Hospital $40 Copayment after deductible Habilitation/Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy in the outpatient department of a Facility or in a Health Care Professional’s office for up to 60 visits per condition per Plan Year. $30 Copayment after deductible (Plan Year: A calendar year ending on December 31 of each year.) Hospice Care only when Physician has certified that You have six (6) months or less to live pursuant to Article 40 of the New York Public Health Law. Outpatient services provided for 210 days by the hospice, including drugs and medical supplies. five (5) visits for supportive care for You and Your immediate family.$25 Copayment after deductible


Habilitation/Rehabilitation Services: 60 visits per condition per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)The visit limit applies to all therapies combined. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. Rehabilitation Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered. Speech/Physical therapy covered only when: therapy is related to the treatment or diagnosis of Your physical illness or injury,(in the case of a covered Child, this includes a medically diagnosed congenital



Y‐CHIROPRATIC

Y‐PT/OT/SPEECH




defect); The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury.

ADDITIONAL OUTPATIENT SERVICES

Clinical Trials: DX: Z00.6, HCPCS: S9992, S9994, S9996, S9988, S9990, G0294,

G0293, G0276, G9057 Dialysis: 90935-90940, 90945-90947, 90963-90966 Home care service 99341-99350,99500-99602 Infertility

Treatment: 89250-89398 Infusion Therapy: 96360-96379,

96401,96402,96409-96425,96521-96523

Medicaid

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office Covered in full Performed in Freestanding Center or Specialist Office Setting Covered in full Performed as Outpatient Hospital Services Covered in full Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan Covered in full Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Covered in full Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office Covered in full Performed in Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be


Experimental and/or Investigational Treatment covered on a case by case basis.

Infertility Treatment: Must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE SPECIALISTS

Infertility: In vitro fertilization, gamete intra-fallopian tube transfers or zygote intra-fallopian tube transfers; Costs for an ovum donor or donor sperm; Sperm storage costs; Cryopreservation and storage of embryos; Ovulation predictor kits; Reversal of tubal ligations; Reversal of vasectomies; Costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers); Cloning; or Medical and surgical procedures that are experimental or investigational, unless Our denial is overturned by an External Appeal Agent.

Y-CLINICAL TRIALS

Y-HOME CARE

Y-INFUSION THERAPY-IN HOME ONLY


performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. Covered in full Second Medical Opinion for the diagnosis of a condition by a qualified physician or appropriate specialist, including one affiliated with a specialty care center. Second Cancer Opinion in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. A second opinion from a Non-Participating Provider on an in network basis when Your attending Physician provides a written Referral to a non-participating Specialist. Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

CANCER PROVIDERS/ONCOLOGISTS AND SURGEONS ARE SPECIALISTS




Treatment: 89250-89398


Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $15 Copayment Performed in Freestanding Center or Specialist Office Setting $15 Copayment Performed as Outpatient Hospital Services $15 Copayment Home Health Care Service will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $15 Copay Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $15 Copayment Home Infusion Counts As Home Visit $15 Copayment


Home Health Care: 40 visits per Plan Year. HOME INFUSION COUNTS AS HOME CARE VISIT (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)

Infertility Treatment: Must be between

Infertility: In vitro fertilization, gamete intra-fallopian tube transfers or zygote intra-fallopian tube transfers; Costs for an ovum donor or donor sperm; Sperm storage costs; Cryopreservation and storage of embryos; Ovulation predictor kits; Reversal of tubal ligations; Reversal of vasectomies; Costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers); Cloning; or Medical and surgical procedures that are experimental

Y-CLINICAL TRIALS

Y-HOME CARE



Infusion Therapy: 96360-96379, 96401,96402,96409-96425,96521-96523

Performed in Specialist Office $15 Copayment Performed as Outpatient Hospital Services $15 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. $0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $25 Copayment Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE SPECIALISTS PLEASE NOTE RATE ABOVE

CANCER PROVIDERS/ONCOLOGISTS AND SURGEONS ARE SPECIALISTS PLEASE NOTE RATES ABOVE.

or investigational, unless Our denial is overturned by an External Appeal Agent.





96401,96402,96409-96425,96521-96523


Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $0 Copayment Performed in Freestanding Center or Specialist Office Setting $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $0 Copayment Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $0 Copayment Home Infusion Counts As Home Visit $0 Copayment Performed in Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment



Infertility Treatment: Must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate.


Y-CLINICAL TRIALS

Y-HOME CARE



Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. $0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. Second Surgical Opinion by a qualified Physician on the need for surgery. $0 Copayment Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

INFERTILITY PROVIDERS ARE SPECIALISTS PLEASE NOTE RATES ABOVE







Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $0 Copayment Performed in Freestanding Center or Specialist Office Setting $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $0 Copayment Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $0 Copayment Home Infusion Counts As Home Visit $0 Copayment



Infertility Treatment: Must be between


Y-CLINICAL TRIALS

Y-HOME CARE




Performed in Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. $0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $0 Copayment Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE SPECIALISTS PLEASE NOTE RATES ABOVE







96401,96402,96409-96425,96521-96523

Child Health Plus

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office Covered in full Performed in Freestanding Center or Specialist Office Setting Covered in full Performed as Outpatient Hospital Services Covered in full Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan. Covered Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office Covered in full Performed in Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. Covered in full Second Medical Opinion for the diagnosis of a condition by a qualified physician or appropriate specialist, including one affiliated with a specialty care center. Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. Second Surgical Opinion by a qualified Physician on the need for surgery.


Home Health Care limitations 40 Visits per calendar year.

Physical and Occupational Therapy The therapy must be skilled therapy. Short-term which means not to exceed 40 visits within one calendar year.

Speech Therapy Services required for a condition amenable to significant clinical improvement within a two month period beginning with the first day of therapy, when performed by an audiologist, language pathologist, a speech therapist and/or otolaryngologist.

Y-CLINICAL TRIALS

Y-HOME CARE



Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.





96401,96402,96409-96425,96521-96523


Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office Covered in full Performed in Freestanding Center or Specialist Office Setting Covered in full Performed as Outpatient Hospital Services Covered in full Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan Covered in full Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Covered in full Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office Covered in full Performed in Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7)


Infertility Treatment: Must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE SPECIALISTS.

CANCER PROVIDERS/ONCOLOGISTS AND SURGEONS ARE SPECIALISTS.


Y-CLINICAL TRIALS

Y-HOME CARE



days of the tests; and The patient is physically present at the Hospital for the tests. Covered in full Second Medical Opinion for the diagnosis of a condition by a qualified physician or appropriate specialist, including one affiliated with a specialty care center. Second Cancer Opinion in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. A second opinion from a Non-Participating Provider on an in network basis when Your attending Physician provides a written Referral to a non-participating Specialist. Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.




HIV Special Needs

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office Covered in full Performed in Freestanding Center or Specialist Office Setting Covered in full Performed as Outpatient Hospital Services Covered in full Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan Covered in full Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Covered in full Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office Covered in full


Infertility Treatment: Must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE

Infertility: In vitro fertilization, gamete intra-fallopian tube transfers or zygote intra-fallopian tube transfers; Costs for an ovum donor or donor sperm; Sperm storage costs; Cryopreservation and storage of embryos; Ovulation predictor kits; Reversal of tubal ligations; Reversal of vasectomies; Costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers); Cloning; or

Y-CLINICAL TRIALS

Y-HOME CARE

Y-INFUSION THERAPY-IN HOME



96401,96402,96409-96425,96521-96523

Performed in Specialist Office Covered in full Performed as Outpatient Hospital Services Covered in full Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. Covered in full Second Medical Opinion for the diagnosis of a condition by a qualified physician or appropriate specialist, including one affiliated with a specialty care center. Second Cancer Opinion in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. A second opinion from a Non-Participating Provider on an in network basis when Your attending Physician provides a written Referral to a non-participating Specialist. Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

SPECIALISTS.

CANCER PROVIDERS/ONCOLOGISTS AND SURGEONS ARE SPECIALISTS.

Medical and surgical procedures that are experimental or investigational, unless Our denial is overturned by an External Appeal Agent.

ONLY




MetroPlus Gold

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $0 Copayment Performed in Freestanding Center or Specialist Office Setting $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $0 Copay Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional.



Infertility: In vitro fertilization, gamete intra-fallopian tube transfers or zygote intra-fallopian tube transfers; Costs for an ovum donor or donor sperm; Sperm storage costs; Cryopreservation and storage of embryos; Ovulation predictor kits; Reversal of tubal ligations; Reversal of vasectomies; Costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers); Cloning; or

Y-CLINICAL TRIALS

Y-HOME CARE

Y-INFUSION THERAPY-IN HOME



96401,96402,96409-96425,96521-96523

Performed in a PCP Office $0 Copayment Home Infusion $0 Copayment Performed in Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. $0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

Infertility Treatment: Must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE SPECIALISTS PLEASE NOTE RATES ABOVE


Medical and surgical procedures that are experimental or investigational, unless Our denial is overturned by an External Appeal Agent.

ONLY





96401,96402,96409-96425,96521-96523


Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. $20 Copayment per visit Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $20 copayment; 200 visits per calendar year Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Subject to applicable copayments, Advanced Infertility Services Not Covered Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $20 Copayment Home Infusion $20 Copayment, 200 visits per calendar year Performed in Specialist Office $40 Copayment Performed as Outpatient Hospital Services $40 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of


Home Health Care: 200 visits per calendar combined services. HOME INFUSION COUNTS AS HOME CARE VISIT


CANCER PROVIDERS/ONCOLOGISTS

Infertility: In vitro fertilization, gamete intra-fallopian tube transfers or zygote intra-fallopian tube transfers; Costs for an ovum donor or donor sperm; Sperm storage costs; Cryopreservation and storage of embryos; Ovulation predictor kits; Reversal of tubal ligations; Reversal of vasectomies; Costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers); Cloning; or Medical and surgical procedures that are experimental or investigational, unless Our denial is overturned by an External Appeal Agent. Telemedicine is not covered.

Y-CLINICAL TRIALS

Y-HOME CARE



the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. Included in hospital admission copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $0 copayment Second Surgical Opinion by a qualified Physician on the need for surgery. $0 copayment Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

AND SURGEONS ARE SPECIALISTS PLEASE NOTE RATES ABOVE.

Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year





96401,96402,96409-96425,96521-96523


Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. $30 Copayment per visit Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $30 copayment; 200 visits per calendar year combined services Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Subject to applicable copayments, Advanced Infertility Treatment Not Covered Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $30 Copayment Home Infusion $30 copayment; 200 visits per calendar year Performed in Specialist Office $50 Copayment Performed as Outpatient Hospital Services $50 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. Included in hospital admission copayment


Home Health Care: 200 visits per calendar year combined services. HOME INFUSION COUNTS AS HOME CARE VISIT



Infertility: In vitro fertilization, gamete intra-fallopian tube transfers or zygote intra-fallopian tube transfers; Costs for an ovum donor or donor sperm; Sperm storage costs; Cryopreservation and storage of embryos; Ovulation predictor kits; Reversal of tubal ligations; Reversal of vasectomies; Costs for and relating to surrogate motherhood (maternity services are Covered for Members acting as surrogate mothers); Cloning; or Medical and surgical procedures that are experimental or investigational, unless Our denial is overturned by an External Appeal Agent. Telemedicine is not covered.

Y-CLINICAL TRIALS

Y-HOME CARE



Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $0 copayment Second Surgical Opinion by a qualified Physician on the need for surgery. $0 copayment Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.






96401,96402,96409-96425,96521-96523


Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office 0% Coinsurance after deductible Performed in Freestanding Center or Specialist Office Setting 0% Coinsurance after deductible Performed as Outpatient Hospital Services 0% Coinsurance after deductible Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan 0% Coinsurance after deductible Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office 0% Coinsurance after deductible Home Infusion 0% Coinsurance after deductible Performed in Specialist Office 0% Coinsurance after deductible Performed as Outpatient Hospital Services 0% Coinsurance after deductible Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. 0% Coinsurance after





Y-CLINICAL TRIALS

Y-HOME CARE



deductible Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. 0% Coinsurance after deductible Second Surgical Opinion by a qualified Physician on the need for surgery. 0% Coinsurance after deductible Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.






96401,96402,96409-96425,96521-96523

BronzePlus

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office 50% Coinsurance after deductible Performed in Freestanding Center or Specialist Office Setting 50% Coinsurance after deductible Performed as Outpatient Hospital Services 50% Coinsurance after deductible Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan 50% Coinsurance after deductible Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office 50% Coinsurance after deductible Home Infusion 50% Coinsurance after deductible Performed in Specialist Office 50% Coinsurance after deductible Performed as Outpatient Hospital Services 50% Coinsurance after deductible Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of


Home Health Care: 40 visits per Plan Year. HOME INFUSION COUNTS AS HOME CARE VISIT (Plan Year: A calendar year ending on December 31 of each year.)



Y-CLINICAL TRIALS

Y-HOME CARE



the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. 50% Coinsurance after deductible Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. 50% Coinsurance after deductible Second Surgical Opinion by a qualified Physician on the need for surgery. 50% Coinsurance after deductible Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.







96401,96402,96409-96425,96521-96523

SilverPlus

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $30 Copayment after deductible Performed in Freestanding Center or Specialist Office Setting $30 Copayment after deductible Performed as Outpatient Hospital Services $30 Copayment after deductible Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $30 Copayment after deductible Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $30 Copayment after deductible Home Infusion $30 Copayment after deductible Performed in Specialist Office $30 Copayment after deductible Performed as Outpatient Hospital Services $30 Copayment after deductible Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests.$0 Copayment after deductible Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $50 copayment after deductible. Second Surgical Opinion by a qualified Physician on the need for surgery. $50 copayment after deductible. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.





Dialysis performed by Non-Participating Providers is limited to10 visits per calendar year


Y-CLINICAL TRIALS

Y-HOME CARE



Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $25 Copayment after deductible Performed in Freestanding Center or Specialist Office Setting $25 Copayment after deductible






96401,96402,96409-96425,96521-96523

GoldPlus

Performed as Outpatient Hospital Services $25 Copayment after deductible Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $25 Copayment after deductible Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $25 Copayment after deductible Home Infusion $25 Copayment after deductible Performed in Specialist Office $25 Copayment after deductible Performed as Outpatient Hospital Services $25 Copayment after deductible Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests.$0 Copayment after deductible Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $40 copayment after deductible. Second Surgical Opinion by a qualified Physician on the need for surgery. $40 copayment after deductible. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second






Y-CLINIAL TRIALS

Y-HOME CARE



opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.





96401,96402,96409-96425,96521-96523

PlatinumPlus

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP or Specialist Office $15 Copayment Performed in Freestanding Center or Specialist Office Setting $15 Copayment Performed as Outpatient Hospital Services $15 Copayment Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan 40 visits per Plan Year. $15 Copayment (Plan Year: A calendar year ending on December 31 of each year.) Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $15 Copayment Home Infusion $15 Copayment Performed in Specialist Office $15 Copayment Performed as Outpatient Hospital Services $15 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests.$0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. $35 Copayment Second Surgical Opinion by a qualified Physician on the need for surgery. $35 Copayment Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.


Dialysis performed by Non-Participating Providers is limited to 10 visits per calendar year.


Infertility Treatment: Must be between the ages of 21 and 44 (inclusive) in order to be considered a candidate. INFERTILITY PROVIDERS ARE SPECIALISTS PLEASE NOTE REATES ABOVE



Y-CLINICAL TRIALS

Y-HOME CARE





G0293, G0276, G9057 Dialysis: 90935-90940, 90945-90947, 90963-90966 Home care service

99341-99350,99500-99602 Injectable Drugs - J0585

Infertility Treatment: 89250-89398 Infusion Therapy: 96360-96379,

96401,96402,96409-96425,96521-96523

Medicare Platinum

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $0 Copayment Performed in Freestanding Center or Specialist Office Setting $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $0 Copayment Injectible Drugs covered under Medicare Part B 20% of the cost for chemotherapy drugs 20% of the cost for other Part B drugs. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office $0 Copayment Home Infusion $0 Copayment Performed in Specialist Office $40 Copayment Performed as Outpatient Hospital Services 20% of Cost Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of


Participation in a clinical trial that is not approved by Medicare you are responsible for the entire cost of your participation in the study.

* Infusion Supplies 20% of Cost Part D Pharmacy Benefit for all settings except Outpatient Hospital

CANCER PROVIDERS/ONCOLOGISTS

Y-CLINICAL TRIALS

Y-HOME CARE


Y-Part B Injectable Drugs J0585


the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests.$0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

AND SURGEONS ARE SPECIALISTS PLEASE NOTE RATES ABOVE.



G0293, G0276, G9057 Dialysis: 90935-90940, 90945-90947, 90963-90966 Home care service

99341-99350,99500-99602 Injectable Drugs - J0585

Infertility Treatment: 89250-89398 Infusion Therapy: 96360-96379,

96401,96402,96409-96425,96521-96523

Medicare Advantage

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office 0% OR 20% of Cost Performed in Freestanding Center or Specialist Office Setting 0% OR 20% of Cost Performed as Outpatient Hospital Services 0% OR 20% of Cost Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan 0% OR 20% Cost Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Injectible Drugs covered under Medicare Part B 0% or 20% of the cost for chemotherapy drugs, depending on level of eligibility 0% or 20% of the cost for other Part B drugs. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office 0% OR 20% of Cost Home Infusion 0% OR 20% of Cost Performed in Specialist Office 0% OR 20% of Cost



CANCER PROVIDERS/ONCOLOGISTS AND SURGEONS ARE SPECIALISTS


Y-CLINICAL TRIALS

Y-HOME CARE


Y-Part B Injectable Drugs J0585


Performed as Outpatient Hospital Services 0% OR 20% of Cost Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. $0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. 0% OR 20% of Cost Second Surgical Opinion by a qualified Physician on the need for surgery. 0% OR 20% of Cost Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.

PLEASE NOTE RATES ABOVE.





FIDA

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office $0 Copayment Performed in Freestanding Center or Specialist Office Setting $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan $0 Copay Private duty nursing services $0 Copay Home delivered and congregate meals $0 Copay Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional.




Y-CLINICAL TRIALS

Y-HOME CARE




Performed in a PCP Office $0 Copayment Home Infusion $0 Copayment Performed in Specialist Office $0 Copayment Performed as Outpatient Hospital Services $0 Copayment Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of



the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests.$0 Copayment Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. Second Surgical Opinion by a qualified Physician on the need for surgery. Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.


Home care service 99341-99350,99500-99602 Teleheath G0425-G0427,G0508-

G0509,G0406-G0408 Physcial/Occupational: 97165-

97168,97161-97164,97750-97799,97110-97546, 97032-97039,97010-97028

Speech/Audiology : 92502-92526,92550-92596,92601-92609

Social work Services: 96150-96155 Nutrition: 97802-97804


Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan Covered in full Telehealth Nutritional Counseling and Nutritional Supplements Home Delivered Meals Home Safety Modification/Improvements Coordination of Care Services


Infertility Treatment Outpatient/Clinic Services Laboratory/Diagnostic Services ESRD/Dialysis

Y-HOME CARE Y-ALL SERVICES ARE

COORDINATED






96401,96402,96409-96425,96521-96523

BronzePlus HSA

Clinical Trials Approved clinical trial to treat either cancer or other life-threatening disease or condition; and referred by a Participating Provider who has concluded that our participation in would be appropriate. Dialysis (i.e. hemodialysis and peritoneal dialysis) Medically necessary as ordered by a qualified medical professional. Renal dialysis may be provided multiple settings: the home, freestanding center, office, outpatient hospital and inpatient hospital based on patient severity. Performed in PCP Office 50% Coinsurance after deductible Performed in Freestanding Center or Specialist Office Setting 50% Coinsurance after deductible Performed as Outpatient Hospital Services 50% Coinsurance after deductible Home Health Care Services will be provided in the member's home by a Certified Home Health Agency (CHHA) Part-time Nursing services, Physical/Occupational Therapy, Speech pathology, Audiology and Social Work services, Personal Care performed by Home Health Aide pursuant to an established care plan 50% Coinsurance after deductible Infertility Treatment diagnosis and treatment (surgical and medical) of infertility when such infertility is the result of malformation, disease or dysfunction. Guidelines established by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the State of New York. Infusion Therapy The administration of drugs directly into the veins using specialized delivery systems. The services must be ordered by a Physician or other authorized Health Care Professional. Performed in a PCP Office 50% Coinsurance after deductible Home Infusion 50% Coinsurance after deductible Performed in Specialist Office 50% Coinsurance after deductible Performed as Outpatient Hospital Services 50% Coinsurance after deductible Preadmission Testing The tests are necessary for and consistent with the diagnosis and treatment of





Y-CLINICAL TRIALS

Y-HOME CARE



the condition for which the surgery is to be performed; Reservations for a Hospital bed and operating room were made prior to the performance of the tests; Surgery takes place within seven (7) days of the tests; and The patient is physically present at the Hospital for the tests. 50% Coinsurance after deductible Second Cancer Opinion from a Non-Participating Provider on an in network Specialist when Your attending Physician provides a written Referral in the event of a positive or negative diagnosis or a recurrence of cancer a recommendation of a course of treatment. 50% Coinsurance after deductible Second Surgical Opinion by a qualified Physician on the need for surgery. 50% Coinsurance after deductible Required Second Surgical Opinion May be required before We preauthorize a surgical procedure. There is no cost to You when We request a second opinion. The second opinion must be given by a board certified Specialist who personally examines You. The second and third surgical opinion consultants may not perform the surgery on You.







96401,96402,96409-96425,96521-96523

SilverPrime








Y-CLINICAL TRIALS

Y-HOME CARE







96401,96402,96409-96425,96521-96523

GoldPrime








Y-CLINIAL TRIALS

Y-HOME CARE



SURGICAL SERVICES POS: 11, 24, 21, 22 Medicaid

Oral Surgery procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery after a mastectomy or partial mastectomy or physical complications including lymphedemas; use of implanted breast prostheses to produce a symmetrical appearance. Other Reconstructive and Corrective Surgery to correct a congenital birth defect of a covered Child which has resulted in a functional defect; Incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or Otherwise Medically Necessary

Oral Surgery: Cysts related to teeth are not Covered.

All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures.

Y‐TRANSPLANT Y-ALL OUT OF NETWORK

Transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. --We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. We do not Cover the medical expenses of a non-Member acting as a donor for You if the non-Member's expenses will be Covered under another health plan or program.

SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY.

We do not Cover: travel expenses, lodging, meals, or other accommodations for donors or guests; donor fees in connection with organ transplant surgery; or routine harvesting and storage of stem cells from newborn cord blood.

Y‐INPATIENT SERVICES

SURGICAL SERVICES POS: 11, 24, 21, 22 Essential Plan 1 Non-Aliessa

Oral Surgery procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery after a mastectomy or partial mastectomy or physical complications including lymphedemas; use of implanted breast prostheses to produce a symmetrical appearance. Other Reconstructive and Corrective Surgery to correct a congenital birth defect of a covered Child which has resulted in a functional defect; Incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or Otherwise Medically Necessary Transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. --We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. We do not Cover the medical expenses of a non-Member acting as a donor for You if the non-Member's expenses will be Covered under another health plan or program.


All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures. We do not Cover: travel expenses, lodging, meals, or other accommodations for donors or guests; donor fees in connection with organ transplant surgery; or routine

Y‐TRANSPLANT



SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery (Surgeon's Fee) $50 Copayment Outpatient Hospital Surgery $50 Copayment Ambulatory Surgical Center $50 Copayment PCP Office $15 Copayment Specialist Office $25 Copayment

harvesting and storage of stem cells from newborn cord blood.

SURGICAL SERVICES POS: 11, 24, 21, 22 Essential Plan 2 Non-Aliessa

Oral Surgery procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery after a mastectomy or partial mastectomy or physical complications including lymphedemas; use of implanted breast prostheses to produce a symmetrical appearance. Other Reconstructive and Corrective Surgery to correct a congenital birth defect of a covered Child which has resulted in a functional defect; Incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or Otherwise Medically Necessary Transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-


All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures. We do not Cover: travel expenses,

Y‐TRANSPLANT



Aldrich Syndrome. --We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. We do not Cover the medical expenses of a non-Member acting as a donor for You if the non-Member's expenses will be Covered under another health plan or program.

SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery $0 Copayment Outpatient Hospital Surgery $0 Copayment Ambulatory Surgical Center $0 Copayment PCP/ Specialist Office Surgery $0 Copayment

lodging, meals, or other accommodations for donors or guests; donor fees in connection with organ transplant surgery; or routine harvesting and storage of stem cells from newborn cord blood.

SURGICAL SERVICES POS: 11, 24, 21, 22 Essential Plan 3/4 Aliessa




Y‐TRANSPLANT




SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery $0 Copayment Outpatient Hospital Surgery $0 Copayment Ambulatory Surgical Center $0 Copayment PCP/ Specialist Office Surgery $0 Copayment


SURGICAL SERVICES POS: 11, 24, 21, 22 Child Health Plus



Oral Surgery: Cysts related to teeth are not Covered. Only necessary procedures for simple extractions and other routine dental surgery not requiring hospitalization, including preoperative care and postoperative care.

All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures. We do not Cover: travel expenses, lodging, meals, or other accommodations for donors or guests; donor fees in connection with organ transplant surgery; or routine harvesting and storage of stem cells from newborn cord blood.

Y‐TRANSPLANT



SURGICAL SERVICES POS: 11, 24, 21, 22 MetroPlus Enhanced (HARP)

Oral Surgery procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery after a mastectomy or partial mastectomy or physical complications including lymphedemas; use of implanted breast prostheses to produce a symmetrical appearance. Other Reconstructive and Corrective Surgery to correct a congenital birth defect of a covered Child which has resulted in a functional defect; Incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or Otherwise Medically Necessary Transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart,



Y‐TRANSPLANT



and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. --We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. We do not Cover the medical expenses of a non-Member acting as a donor for You if the non-Member's expenses will be Covered under another health plan or program.



SURGICAL SERVICES POS: 11, 24, 21, 22 HIV Special Needs

Oral Surgery procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery after a mastectomy or partial mastectomy or physical complications including lymphedemas; use of implanted breast prostheses to produce a symmetrical appearance. Other Reconstructive and Corrective Surgery to correct a congenital birth defect of a covered Child which has resulted in a functional defect; Incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or Otherwise Medically Necessary




Transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome. --We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. We do not Cover the medical expenses of a non-Member acting as a donor for You if the non-Member's expenses will be Covered under another health plan or program.




SURGICAL SERVICES POS: 11, 24, 21, 22 MetroPlus Gold






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery $0 Copayment per admission Outpatient Hospital Surgery $0 Copayment Ambulatory Surgical Center $0 Copayment PCP/ Specialist Office Surgery $0 Copayment



SURGICAL SERVICES POS: 11, 24, 21, 22 MetroPlus GoldCare I


Oral Surgery: Cysts related to teeth are not Covered..




SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Ambulatory surgery $100 copayment (same in OP facility or physician office) Inpatient Surgery Included in hospital admission copayment



SURGICAL SERVICES POS: 11, 24, 21, 22 MetroPlus GoldCare II






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Ambulatory surgery $200 copayment (same in OP facility or physician office) Inpatient Surgery Included in hospital admission copayment



SURGICAL SERVICES POS: 11, 24, 21, 22 MedPlus Catastrophic

Oral Surgery procedures for jaw bones or surrounding tissue and dental services for the repair or replacement of sound natural teeth that are required due to accidental injury. Replacement is Covered only when repair is not possible. Dental services must be obtained within 12 months of the injury. Oral surgical procedures for jaw bones or surrounding tissue and dental services necessary due to congenital disease or anomaly. Removal of tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth. Surgical/nonsurgical medical procedures for temporomandibular joint disorders and orthognathic surgery. Reconstructive Breast Surgery after a mastectomy or partial mastectomy or physical complications including lymphedemas; use of implanted breast prostheses to produce a symmetrical appearance. Other Reconstructive and Corrective Surgery to correct a congenital birth defect of a covered Child which has resulted in a functional defect; Incidental to surgery or follows surgery that was necessitated by trauma, infection or disease of the involved part; or Otherwise Medically Necessary Transplants determined to be non-experimental and non-investigational. Covered transplants include but are not limited to: kidney, corneal, liver, heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia, leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.



Y‐TRANSPLANT



--We Cover the Hospital and medical expenses, including donor search fees, of the Member-recipient. We Cover transplant services required by You when You serve as an organ donor only if the recipient is a Member. We do not Cover the medical expenses of a non-Member acting as a donor for You if the non-Member's expenses will be Covered under another health plan or program.

SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery: 0% Coinsurance after Deductible Outpatient Hospital Surgery: 0% Coinsurance after Deductible Ambulatory Surgical Center: 0% Coinsurance after Deductible PCP/Specialist Office Surgery: 0% Coinsurance after Deductible


SURGICAL SERVICES POS: 11, 24, 21, 22 BronzePlus






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery: 50% Coinsurance after deductible Outpatient Hospital Surgery: 50% Coinsurance after deductible Ambulatory Surgical Center: 50% Coinsurance after deductible PCP/Specialist Office Surgery: 50% Coinsurance after deductible



SURGICAL SERVICES POS: 11, 24, 21, 22 SilverPlus



All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures. We do not Cover: travel expenses, lodging, meals, or other accommodations for donors or guests; donor fees in connection with

Y‐TRANSPLANT



SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery (Surgeon's Fee): $100 Copayment after deductible Outpatient Hospital Surgery: $100 Copayment after deductible Ambulatory Surgical Center:$100 Copayment after deductible PCP Office: $30 Copayment after deductible Specialist Office: $50 Copayment after deductible

organ transplant surgery; or routine harvesting and storage of stem cells from newborn cord blood.

SURGICAL SERVICES POS: 11, 24, 21, 22 GoldPlus






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery (Surgeon's Fee): $100 Copayment after deductible Outpatient Hospital Surgery:$100 Copayment after deductible Surgery Performed at an Ambulatory Surgical Center: $100 Copayment after deductible PCP office: $25 Copayment after deductible Specialist office: $40 Copayment after deductible



SURGICAL SERVICES POS: 11, 24, 21, 22 PlatinumPlus






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery (Surgeon's Fee): $100 Copayment Outpatient Hospital Surgery:$100 Copayment Ambulatory Surgical Center: $100 Copayment PCP office: $15 Copayment Specialist office $35 Copayment



SURGICAL SERVICES POS: 11, 24, 21, 22 Medicare Platinum





Y‐INPATIENT SERVICES Y-ALL OUT OF NETWORK

SURGICAL SERVICES POS: 11, 24, 21, 22 Medicare Advantage





Y‐TRANSPLANT


SURGICAL SERVICES POS: 11, 24, 21, 22 FIDA





Y‐TRANSPLANT


SURGICAL SERVICES N/A MetroPlus Managed Long Term Care (MLTC)


SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. NOT COVERED BENEFIT



N/A N/A

SURGICAL SERVICES POS: 11, 24, 21, 22 BronzePlus HSA






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery: 50% Coinsurance after deductible Outpatient Hospital Surgery: 50% Coinsurance after deductible Ambulatory Surgical Center: 50% Coinsurance after deductible PCP/Specialist Office Surgery: 50% Coinsurance after deductible



SURGICAL SERVICES POS: 11, 24, 21, 22 SilverPrime






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery (Surgeon's Fee): $100 Copayment after deductible Outpatient Hospital Surgery: $100 Copayment after deductible Ambulatory Surgical Center:$100 Copayment after deductible PCP Office: $35 Copayment after deductible Specialist Office: $55 Copayment after deductible



SURGICAL SERVICES POS: 11, 24, 21, 22 GoldPrime






SURGEONS ARE SPECIALISTS SERVICES CAN BE IN OFFICE, AMBULATORY SURGERY, INPATIENT OR OUTPATIENT HOSPITAL. PLEASE FOLLOW THE RULES AS THEY APPLY. Inpatient Hospital Surgery (Surgeon's Fee): $100 Copayment after deductible Outpatient Hospital Surgery:$100 Copayment after deductible Surgery Performed at an Ambulatory Surgical Center: $100 Copayment after deductible PCP office: $25 Copayment after deductible Specialist office: $40 Copayment after deductible



Inpatient Services: 99221-99223,99231-99239 Newborn 99460-

99463,99477 Postpartum care: 59430

Hospital Services Acute care or treatment given or ordered by a Health Care Professional for an illness, injury or disease of a severity that must be treated on an inpatient basis including: Up to 365 days per year (366 days during leap year) for all medically necessary inpatient hospital services (including care, treatment, maintenance and nursing services as required). Other covered services can encompass a full range of necessary diagnostic and therapeutic care including medical, surgical, nursing, radiological and rehabilitative services. Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Pasteurized donor human milk (PDHM) for inpatient use is a covered benefit.

Rehabilitation: Speech and physical therapy only when: Such therapy is related to the treatment or diagnosis of Your physical illness or injury; The therapy is ordered by a Physician; and

Private/Special duty nurses, private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. . Radio, telephone or television expenses, or beauty or

INPATIENT SERVICES

Speech Therapy- 92507, 92508 Physical Therapy- 97161, 97162, 97163, 97164 Occupational Therapy-

97165, 97166, 97167, 97168 Skilled Nursing Facility Services: 99304-

99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479

Medicaid

Rehabilitation Services Residential Health Care Facility (Nursing Home) Services (RCCF) Long Term Care (LTC) inpatient nursing home service licensed under Article 28 for members who require medical supervision, 24 hours of nursing care, assistance with activities of daily living (ADLs) but who does not require acute care hospital services and services could not satisfactorily be met in the member's home or in the community.

Skilled Nursing Facility admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. Residential Health Care Facility (Nursing Home) Services (RCCF) Long Term Care (LTC) inpatient nursing home service licensed under Article 28 for members who require medical supervision, 24 hours of nursing care, assistance with activities of daily living (ADLs) but who does not require acute care hospital services and services could not satisfactorily be met in the member's home or in the community. End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree

You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered.

barber services. Any charges incurred after the day We advise You it is no longer Medically Necessary for You to receive inpatient care, unless Our denial is overturned by an External Appeal Agent.

Residential Health Care Facility (RCCF) covered except for enrollees under age 21 in long term placement status.

YES YES

that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. Covered in full

INPATIENT SERVICES


99463,99477 Speech Therapy- 92507, 92508

Physical Therapy- 97161, 97162, 97163, 97164 Occupational Therapy-


Hospital Services Acute care or treatment given or ordered by a Health Care Professional for an illness, injury or disease of a severity that must be treated on an inpatient basis including: Up to 365 days per year (366 days during leap year) for all medically necessary inpatient hospital services (including care, treatment, maintenance and nursing services as required). Other covered services can encompass a full range of necessary diagnostic and therapeutic care including medical, surgical, nursing, radiological and rehabilitative services.

Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full Physician and Midwife Services for Delivery $50

Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. 200 days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which

Skilled Nursing Facility Limit 200 Days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any

Private/Special duty nurses, private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. . Radio, telephone or television expenses, or beauty or barber services. Any charges incurred after the day We advise You it is no longer Medically Necessary for You to receive inpatient care, unless Our denial is overturned by an

YES YES

97165, 97166, 97167, 97168 Nursing Facility Services: 99304-99306,99307-

99310,99315-99316,99318

the Contract is in effect.)

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor.

$150 Copayment per hospital admission

anniversary date thereafter, during which the Contract is in effect.)

External Appeal Agent.

Long Term Nursing Home Care is not covered by this Contract

INPATIENT SERVICES


99463,99477 Postpartum care: 59430 Speech Therapy- 92507, 92508



99306,99307-99310,99315-99316,99318



Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Breastfeeding support , counseling and supplies, including Breast Pumps. Covered in full

Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. 200 days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)

Skilled Nursing Facility Limit 200 Days per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during

Private/Special duty nurses, private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. . Radio, telephone or television expenses, or beauty or barber services. Any charges incurred after the day We advise You it is no longer Medically Necessary for You to receive inpatient care, unless Our denial is overturned by an External Appeal Agent.

YES YES

Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. $0 No Cost sharing by member

which the Contract is in effect.) Long Term Nursing Home Care is not covered by this Contract

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479



Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Breastfeeding support , counseling and supplies, including Breast Pumps. Covered in full

Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. 200 days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited

Skilled Nursing Facility Limit 200 Days per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)


Long Term Nursing Home Care is not covered by this Contract

YES YES

external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. $0 No Cost sharing by member

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479

Child Health Plus


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns.

Rehabilitation Services Inpatient Services in a Nursing Home, Rehabilitation Facility, or Any Other Facility Not Expressly Covered by this Contract.

Skilled Nursing Facility Inpatient Services in a Nursing Home, Rehabilitation Facility, or Any Other Facility Not Expressly Covered by this Contract.

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. Covered in full


YES YES

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318



Rehabilitation Services Residential Health Care Facility (Nursing Home) Services (RCCF) Long Term Care (LTC) inpatient nursing home service licensed under Article 28 for members who require medical supervision, 24 hours of nursing care, assistance with activities of daily living (ADLs) but who does not require acute care hospital services and services could not satisfactorily be met in the member's home or in the community. Long term stays are not a covered benefit in the HARP product.

Skilled Nursing Facility admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. Residential Health Care Facility (Nursing Home) Services (RCCF) Long Term Care (LTC) inpatient nursing home service licensed under Article 28 for members who require medical supervision, 24 hours of nursing care, assistance with activities of daily living (ADLs) but who does not require acute care hospital services and services could not satisfactorily be met in the member's home or in the community. End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28


YES YES


Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. Covered in full

Long term stays are not a covered benefit in the HARP product


99463,99477 Postpartum care: 59430



Private/Special duty nurses, private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. . Radio, telephone or television expenses, or beauty or

INPATIENT SERVICES

Speech Therapy- 92507, 92508 Physical Therapy- 97161, 97162, 97163, 97164 Occupational Therapy-


99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479

HIV Special Needs

Rehabilitation Services Residential Health Care Facility (Nursing Home) Services (RCCF) Long Term Care (LTC) inpatient nursing home service licensed under Article 28 for members who require medical supervision, 24 hours of nursing care, assistance with activities of daily living (ADLs) but who does not require acute care hospital services and services could not satisfactorily be met in the member's home or in the community.

Skilled Nursing Facility admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. Residential Health Care Facility (Nursing Home) Services (RCCF) Long Term Care (LTC) inpatient nursing home service licensed under Article 28 for members who require medical supervision, 24 hours of nursing care, assistance with activities of daily living (ADLs) but who does not require acute care hospital services and services could not satisfactorily be met in the member's home or in the community. End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree

You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered.

barber services. Any charges incurred after the day We advise You it is no longer Medically Necessary for You to receive inpatient care, unless Our denial is overturned by an External Appeal Agent.

Residential Health Care Facility (RCCF) covered except for enrollees under age 21 in long term placement status.

YES YES

that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. Covered in full

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318

MetroPlus Gold



Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us.


Skilled Nursing Facility Limit 200 Days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)


YES YES

Hospice care 99377-99378,T2042-T2046,G9474,G9477-G9479 $0 Copayment per hospital admission Custodial, convalescent or domiciliary care is not

Covered.

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479





End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited

Skilled Nursing Facility Limit 200 Days per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)


Custodial, convalescent or domiciliary care is not Covered

YES YES

external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor.

$300 copayment per hospital admission

INPATIENT SERVICES








Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation0 admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us.

Skilled Nursing Facility Limit 200 Days per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during


YES YES

99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479


$500 copayment per hospital admission

which the Contract is in effect.) Custodial, convalescent or domiciliary care is not Covered

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479






0% Coinsurance after deductible per hospital admission

Skilled Nursing Facility Limit 200 Days per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)



YES YES

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318

BronzePlus


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full Physician and Midwife Services for Delivery 50% Coinsurance after Deductible

Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. 200 days per Plan Year (Plan Year: A calendar year ending on December 31 of each year.)

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28

Skilled Nursing Facility Limit 200 Days per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)


YES YES


Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor.



INPATIENT SERVICES


99463,99477 Speech Therapy- 92507, 92508



99310,99315-99316,99318

SilverPlus


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. $1500 Copayment after deductible per hospital admission Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full Physician and Midwife Services for Delivery $100 Copayment after Deductible



$1500 Copayment after deductible per hospital admission

Rehabilitation: Speech and physical therapy only when: Such therapy is related to the treatment or diagnosis of Your physical illness or injury; The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered.



Custodial, convalescent or domiciliary care is not Covered.

YES YES

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479

GoldPlus


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. $1000 Copayment after deductible Physician and Midwife Services for Delivery $100 Copayment after Deductible Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full



Skilled Nursing Facility Limit 200 Days per Plan Year (Plan Year: A calendar year ending on December 31 of each year.)



YES YES

$1000 Copayment after deductible

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318

PlatinumPlus


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. $500 Copayment after deductible per hospital admission Physician and Midwife Services for Delivery $100 Copayment Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full


End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract



YES YES


until the External Appeal Agent renders a decision in Our favor.

$500 Copayment after deductible per hospital admission


INPATIENT SERVICES


99463,99477 Speech Therapy- 92507, 92508


Medicare Platinum

Hospital Services Acute care or treatment given or ordered by a Health Care Professional for an illness, injury or disease of a severity that must be treated on an inpatient basis including: Up to 365 days per year (366 days during leap year) for all medically necessary inpatient hospital services (including care, treatment, maintenance and nursing services as required). Other covered services can encompass a full range of necessary diagnostic and therapeutic care including medical, surgical, nursing, radiological and rehabilitative services. Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Rehabilitation Services Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.” End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor.

Plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.


Private/Special duty nurses, private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. . Radio, telephone or television expenses, or beauty or barber services. Any charges incurred after the day We advise You it is

YES YES


99310,99315-99316,99318

INPATIENT FEES $225 Copayment per day for days 1 through 8 You pay nothing per day for days 9 through 90. Skilled Nursing Facility (SNF) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. Our

You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date

no longer Medically Necessary for You to receive inpatient care, unless Our denial is overturned by an External Appeal Agent.

Plan covers 100 days in a SNF. You pay nothing for days 1 through 20 $167.50 copay per day for days 21 through 100

of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered.

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479

Medicare Advantage

Hospital Services Acute care or treatment given or ordered by a Health Care Professional for an illness, injury or disease of a severity that must be treated on an inpatient basis including: Up to 365 days per year (366 days during leap year) for all medically necessary inpatient hospital services (including care, treatment, maintenance and nursing services as required). Other covered services can encompass a full range of necessary diagnostic and therapeutic care including medical, surgical, nursing, radiological and rehabilitative services. Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns.

Rehabilitation Services Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.” Fee-for-Service Medicaid covers the Medicare deductibles, copays, and coinsurances -up to 365 days per year (366 days for leap year).

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. INPATIENT FEES $0 OR $1340 deductible for days 1 through 60. $335 copayment per day for days 61 through 90 $670 copayment per day for 60 lifetime reserve days.


Rehabilitation: Speech and physical therapy only when: Such therapy is related to the treatment or diagnosis of Your physical illness or injury; The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date


YES YES

Skilled Nursing Facility (SNF) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. Our Plan pays up to 100 days in a SNF. $0 OR You pay nothing for days 1 through 20. $167.50 copay per day for days 21 through 100.


INPATIENT SERVICES




97165, 97166, 97167, 97168 Skilled FIDA



Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy. Unlimited number of days

Skilled Nursing Facility admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. Unlimited number of days

Assisted living program - in an adult home or enriched housing setting.



Private/Special duty nurses, private rooms (unless a private room is Medically Necessary), or medications and supplies You take home from the Facility. . Radio, telephone or television expenses, or beauty or barber services. Any charges incurred after the day We advise You it is

YES YES

Nursing Facility Services: 99304-99306,99307-99310,99315-99316,99318


End of Life Care ( Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract

You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date

no longer Medically Necessary for You to receive inpatient care, unless Our denial is overturned by an External Appeal Agent.

until the External Appeal Agent renders a decision in Our favor. $0 Copayment per hospital admission


INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479


Hospital Services Acute care or treatment given or ordered by a Health Care Professional for an illness, injury or disease of a severity that must be treated on an inpatient basis including: Up to 365 days per year (366 days during leap year) for all medically necessary inpatient hospital services (including care, treatment, maintenance and nursing services as required). Other covered services can encompass a full range of necessary diagnostic and therapeutic care including medical, surgical, nursing, radiological and rehabilitative services. Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Rehabilitation Services consisting of physical therapy, speech therapy and occupational therapy for up to one (1) consecutive 60 day period per condition per lifetime. For the purposes of this benefit, "per condition" means the disease or injury causing the need for the therapy. Skilled Nursing Facility admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. NOT COVERED BENEFIT EXCEPT SKILLED NURSING FACILITIES

MLTC members are entitled to medically necessary Nursing Home Care (skilled nursing facility) as per Appendix G


Y-Skilled Nursing Facility (Nursing Home Care)

Y-Skilled Nursing Facility (Nursing Home Care)

INPATIENT SERVICES





99306,99307-99310,99315-99316,99318

BronzePlus HSA


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full Physician and Midwife Services for Delivery 50% Coinsurance after Deductible

Skilled Nursing Facility (including Cardiac and Pulmonary Rehabilitation) admission care and treatment must be supported by a treatment plan prepared by Your Provider and approved by Us. 200 days per Plan Year (Plan Year: A calendar year ending on December 31 of each year.)

End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28



YES YES


Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor.



INPATIENT SERVICES


99463,99477 Speech Therapy- 92507, 92508


97165, 97166, 97167, 97168 Nursing

SilverPrime


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. $1500 Copayment after deductible per hospital admission Breastfeeding support, counseling and supplies, including Breast Pumps. Covered in full Physician and Midwife Services for Delivery $100 Copayment after Deductible



All transplants must be prescribed by Your Specialist(s). Additionally, all transplants must be performed at Hospitals that We have specifically approved and designated to perform these procedures. We do not Cover: travel expenses, lodging, meals, or other


Y‐TRANSPLANT



Facility Services: 99304-99306,99307-99310,99315-99316,99318


accommodations for donors or guests; donor fees in connection with organ transplant surgery; or routine harvesting and storage of stem cells from newborn cord blood.


INPATIENT SERVICES





99306,99307-99310,99315-99316,99318 Hospice care 99377-99378,T2042-

T2046,G9474,G9477-G9479

GoldPrime


Maternity Care mother, and inpatient newborn care in a Hospital for the infant, for at least 48 hours following a normal delivery and at least 96 hours following a caesarean section delivery, regardless of whether such care is Medically Necessary. The care provided shall include parent education, assistance, and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. We provide routine Home Care visits to postpartum mothers and newborns. $1000 Copayment after deductible Breastfeeding support , counseling and supplies, including Breast Pumps. Covered in full Physician and Midwife Services for Delivery $100 Copayment after Deductible


End of Life Care (Hospice) a diagnosis of advanced cancer with fewer than 60 days to live, We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility that specializes in the care of terminally ill patients. Your attending Physician and the Facility’s medical director must agree that Your care will be appropriately provided at the Facility. If We disagree with Your admission to the Facility, We have the right to initiate an expedited external appeal to an External Appeal Agent. We will Cover and reimburse the Facility for Your care, subject to any applicable limitations in this Contract until the External Appeal Agent renders a decision in Our favor. $1000 Copayment after deductible

Rehabilitation: Speech and physical therapy only when: Such therapy is related to the treatment or diagnosis of Your physical illness or injury; The therapy is ordered by a Physician; and You have been hospitalized or have undergone surgery for such illness or injury. Services must begin within six (6) months of the later to occur: The date of the injury or illness that caused the need for the therapy; The date You are discharged from a Hospital where surgical treatment was rendered; or The date outpatient surgical care is rendered.



YES YES

Skilled Nursing Facility Limit 200 Days per Calendar.

MENTAL HEALTH CARE PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon Medicaid

Outpatient Mental Health Care Services , including but not limited to partial hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Coverage for outpatient services for mental health care includes Facilities that have been issued an operating certificate pursuant to Article 31 of the New York Mental Hygiene Law or are operated by the New York State Office of Mental Health and, in other states, to similarly licensed or certified Facilities; and services provided by a licensed psychiatrist or psychologist; a licensed clinical social worker who has at least three (3) years of additional experience in psychotherapy; a licensed mental health counselor; a 48 licensed psychoanalyst; or a professional corporation or a university faculty practice corporation thereof.

Enrollees must be allowed to self-refer for one (1) mental health assessment from a MetroPlus’ participating provider in a twelve (12) month period. In the case of children, such referrals may originate at the request of a school guidance counselor or similar source.

All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning

Benefits or services deemed to be cosmetic in nature on the grounds that changing or improving an individual’s appearance is justified by the individual’s mental health needs; - Mental health benefits or services for individuals who are incarcerated, confined or committed to a local correctional facility or prison or -Services solely because they are ordered by a court.

Beacon Phone (855) 371-9228

- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH Covered in full


OUTPATIENT SERVICES Beacon Essential Plan 1 Non-Aliessa

Outpatient Mental Health Care Service s, including but not limited to partial hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Coverage for outpatient services for mental health care includes Facilities that have been issued an operating certificate pursuant to Article 31 of the New York Mental Hygiene Law or are operated by the New York State Office of Mental Health and, in other states, to similarly licensed or certified Facilities; and services provided by a licensed psychiatrist or psychologist; a licensed clinical social worker who has at least three (3) years of additional experience in psychotherapy; a licensed mental health counselor; a 48 licensed psychoanalyst; or a professional corporation or a university faculty practice corporation thereof.

Enrollees must be allowed to self-refer for one (1) mental health assessment from a MetroPlus’ participating provider in a twelve (12) month period.

All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization

Benefits or services deemed to be cosmetic in nature on the grounds that changing or improving an individual’s appearance is justified by the individual’s mental health needs; - Mental health benefits or services for individuals who are incarcerated, confined or committed to a local

Beacon Phone (855) 371‐9228

Beacon Phone (855) 371‐9229

- Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $15 Copayment

correctional facility or prison or -Services solely because they are ordered by a court.


OUTPATIENT SERVICES Beacon Essential Plan 2 Non-Aliessa

Outpatient Mental Health Care Services, including but not limited to partial hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Coverage for outpatient services for mental health care includes Facilities that have been issued an operating certificate pursuant to Article 31 of the New York Mental Hygiene Law or are operated by the New York State Office of Mental Health and, in other states, to similarly licensed or certified Facilities; and services provided by a licensed psychiatrist or psychologist; a licensed clinical social worker who has at least three (3) years of additional experience in psychotherapy; a licensed mental health counselor; a 48 licensed psychoanalyst; or a professional corporation or a university faculty practice corporation thereof.


All medically necessary outpatient mental health services are covered and include but are not limited to the following : - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $0 No cost sharing by member





OUTPATIENT SERVICES Beacon Essential Plan 3/4 Aliessa

Outpatient Mental Health Care Service s, including but not limited to partial hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Coverage for outpatient services for mental health care includes Facilities that have been issued an operating certificate pursuant to Article 31 of the New York Mental Hygiene Law or are operated by the New York State Office of Mental Health and, in other states, to similarly licensed or certified Facilities; and services provided by a licensed psychiatrist or psychologist; a licensed clinical social worker who has at least three (3) years of additional experience in psychotherapy; a licensed mental health counselor; a 48 licensed psychoanalyst; or a professional corporation or a university faculty practice corporation thereof.


All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH Covered in full





OUTPATIENT SERVICES Beacon Child Health Plus


All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education




- Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH Covered in full


OUTPATIENT SERVICES Beacon MetroPlus Enhanced (HARP)









OUTPATIENT SERVICES Beacon HIV Special Needs








MENTAL HEALTH CARE



Benefits or services deemed to be cosmetic in nature on the grounds that changing or improving an individual’s appearance is justified by the individual’s mental health

PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon MetroPlus Gold All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning

needs; - Mental health benefits or services for individuals who are incarcerated, confined or committed to a local correctional facility or prison or -Services solely because they are ordered by a court.



- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $0 Copayment

MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon MetroPlus GoldCare I All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning




- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $20 copay; unlimited visits per calendar year

MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon MetroPlus GoldCare II All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning




- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $30 copay; unlimited visits per calendar year

MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon MedPlus Catastrophic





- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH 0% Coinsurance after deductible

MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon BronzePlus All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning





MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon SilverPlus All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning




- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $30 Copayment after deductible

MENTAL HEALTH CARE

Outpatient Mental health Care Services, including but not limited to partial hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Coverage for outpatient services for mental health care includes Facilities that have been issued an operating certificate pursuant to Article 31 of the New York Mental Hygiene Law or are operated by the New York State Office of Mental Health and, in other states, to similarly licensed or certified Facilities; and services provided by a licensed psychiatrist or psychologist; a licensed clinical social worker who has at least three (3) years of additional experience in psychotherapy; a licensed mental health counselor; a 48 licensed psychoanalyst; or a professional corporation or a university faculty practice corporation thereof.



PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon GoldPlus All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning





MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon PlatinumPlus All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning




- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $15 Copayment


OUTPATIENT SERVICES Beacon Medicare Platinum



All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $40 copayment per visit for individual or group therapy





OUTPATIENT SERVICES Beacon Medicare Advantage



All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH 0% OR 20% of the cost per visit for individual or group therapy





OUTPATIENT SERVICES Beacon FIDA



All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management




- Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH - Assertive community treatment (ACT) - Community integration counseling and Community transitional services - Continuing day treatment - Intensive psychiatric rehabilitation treatment programs - Mobile mental health treatment Covered in full


OUTPATIENT SERVICES Beacon MetroPlus Managed Long Term Care (MLTC)



All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning - Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH NOT COVERED BENEFIT




MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon BronzePlus HSA All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning





MENTAL HEALTH CARE




PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon SilverPrime All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning




- Verbal therapies - Education - Symptom Management - Case Management Services - Crisis Intervention & Outreach Services - Clozapine Monitoring - Collateral Services as Certified by OMH $35 Copayment after deductible ((first 3 visits to Outpatient Mental Health Care not subject to Deductible)

MENTAL HEALTH CARE

Outpatient Mental health Care Services, including but not limited to partial hospitalization program services and intensive outpatient program services, relating to the diagnosis and treatment of mental, nervous and emotional disorders. Coverage for outpatient services for mental health care includes Facilities that have been issued an operating certificate pursuant to Article 31 of the New York Mental Hygiene Law or are operated by the New York State Office of Mental Health and, in other states, to similarly licensed or certified Facilities; and services provided by a licensed psychiatrist or psychologist; a licensed clinical social worker who has at least three (3) years of additional experience in psychotherapy; a licensed mental health counselor; a 48 licensed psychoanalyst; or a professional corporation or a university faculty practice corporation thereof.



PROVIDED BY BEACON

OUTPATIENT SERVICES Beacon GoldPrime All medically necessary outpatient mental health services are covered and include but are not limited to the following: - Assessment - Stabilization - Treatment Planning - Discharge Planning






INPATIENT SERVICES

Beacon Medicaid

Inpatient Mental Health Care Services relating to the diagnosis and treatment of mental, nervous and emotional disorders Coverage for inpatient services for mental health care is limited to Facilities defined in New York Mental Hygiene Law Section 1.03(10), such as: -A psychiatric center or inpatient Facility under the jurisdiction of the New York State Office of Mental Health; -A state or local government run psychiatric inpatient Facility; -A part of a Hospital providing inpatient mental health care services under an operating certificate issued by the New York State Commissioner of Mental Health; -A comprehensive psychiatric emergency program or other Facility providing inpatient mental health care that has been issued an operating certificate by the New York State Commissioner of Mental Health; and, in other states, to similarly licensed or certified Facilities.

Inpatient mental health care services relating to the diagnosis and treatment of mental, nervous and emotional disorders received at Facilities that provide residential treatment, including room and board charges. Coverage for



residential treatment services is limited to residential treatment facilities that are part of a comprehensive care center for eating disorders identified pursuant to Article 27-J of the New York Public Health Law; and, in other states, to Facilities that are licensed or certified to provide the same level of treatment.

ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. Covered in full


INPATIENT SERVICES

Beacon Essential Plan 1 Non-Aliessa

Inpatient Mental Health Care Services relating to the diagnosis and treatment of mental, nervous and emotional disorders Coverage for inpatient services for mental health care is limited to Facilities defined in New York Mental Hygiene Law Section 1.03(10), such as: - A psychiatric center or inpatient Facility under the jurisdiction of the New York State Office of Mental Health; -A state or local government run psychiatric inpatient Facility; -A part of a Hospital providing inpatient mental health care services under an operating certificate issued by the New York State Commissioner of Mental Health; - A comprehensive psychiatric emergency program or other Facility providing inpatient mental health care that has been issued an operating certificate by the New York State Commissioner of Mental Health; and, in other states, to similarly licensed or certified Facilities.





ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $150 Copayment per hospital admission


INPATIENT SERVICES







ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $0 No cost sharing by member


INPATIENT SERVICES

Beacon Essential Plan 3/4 Aliessa








INPATIENT SERVICES

Beacon Child Health Plus








INPATIENT SERVICES

Beacon MetroPlus Enhanced (HARP)








INPATIENT SERVICES

Beacon HIV Special Needs








INPATIENT SERVICES

Beacon MetroPlus Gold








INPATIENT SERVICES

Beacon MetroPlus GoldCare I


Inpatient mental health care services relating to the diagnosis and treatment of mental, nervous and emotional disorders received at Facilities that provide residential treatment, including room and board charges. Coverage for residential treatment services is limited to residential treatment facilities that are part of a comprehensive care center for eating disorders identified pursuant to Article 27-J of the New York Public Health Law; and, in other states, to Facilities that are licensed or certified to provide the same level of treatment.

ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $300 copay per hospital admission, unlimited days per calendar year




INPATIENT SERVICES

Beacon MetroPlus GoldCare II






ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $500 copay per hospital admission, unlimited days per calendar year


INPATIENT SERVICES

Beacon MedPlus Catastrophic

Inpatient Mental Health Care Service s relating to the diagnosis and treatment of mental, nervous and emotional disorders Coverage for inpatient services for mental health care is limited to Facilities defined in New York Mental Hygiene Law Section 1.03(10), such as: -A psychiatric center or inpatient Facility under the jurisdiction of the New York State Office of Mental Health; -A state or local government run psychiatric inpatient Facility; -A part of a Hospital providing inpatient mental health care services under an operating certificate issued by the New York State Commissioner of Mental Health; -A comprehensive psychiatric emergency program or other Facility providing inpatient mental health care that has been issued an operating certificate by the New York State Commissioner of Mental Health; and, in other states, to similarly licensed or certified Facilities.





ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. 0% Coinsurance after deductible per hospital admission


INPATIENT SERVICES

Beacon BronzePlus








INPATIENT SERVICES

Beacon SilverPlus






ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $1500 Copayment after deductible per hospital admission


INPATIENT SERVICES

Beacon GoldPlus








INPATIENT SERVICES

Beacon PlatinumPlus








INPATIENT SERVICES

Beacon Medicare Platinum



ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $195 copayment for days 1 through 8 $0 (nothing) for days 9 through 90

Plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Plan covers 90 days for each benefit period for an inpatient hospital stay. Plan also covers 60 "lifetime reserve days" These are "extra" days that plan will cover. If your hospital stay is longer than 90 days, you can use these "extra" days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.




INPATIENT SERVICES

Beacon Medicare Advantage



ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $0 OR $1340 deductible for days 1 through 60. $335 copayment per day for days 61 through 90 $670 copayment per day for 60 lifetime reserve days.





INPATIENT SERVICES

Beacon FIDA

Inpatient Mental Health Care Services relating to the diagnosis and treatment of mental, nervous and emotional disorders Coverage for inpatient services for mental health care is limited to Facilities defined in New York Mental Hygiene Law Section 1.03(10), such as: -A psychiatric center or inpatient Facility under the jurisdiction of the New York State Office of Mental Health; -A state or local government run psychiatric inpatient Facility; -A part of a Hospital providing inpatient mental health care services under an operating certificate issued by the New York State Commissioner of Mental Health; -A comprehensive psychiatric emergency program (CPEPs) or other Facility providing inpatient mental health care that has been issued an operating certificate by the New York State Commissioner of Mental Health; and, in other states, to similarly licensed or certified Facilities.


ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. $0 Copayment





INPATIENT SERVICES

Beacon MetroPlus Managed Long Term Care (MLTC)



N/A N/A


ALL MEDICALLY NECESSARY INPATIENT MENTAL HEALTH SERVICES BOTH VOLUNTARY AND INVOLUNTARY ADMISSIONS. NOT COVERED BENEFIT


INPATIENT SERVICES

Beacon BronzePlus HSA








INPATIENT SERVICES

Beacon SilverPrime








INPATIENT SERVICES

Beacon GoldPrime








SUBSTANCE USE OUTPATIENT SERVICES

Beacon Medicaid

Outpatient Substance Use Services relating to the diagnosis and treatment substance use disorder, including methadone treatment. Such Coverage is limited to Facilities in New York State that are certified by OASAS or licensed by OASAS as outpatient clinics or medically supervised ambulatory substance abuse programs, and, in other states, to those that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Coverage is also available in a professional office setting for outpatient substance use disorder services relating to the diagnosis and treatment of alcoholism, substance use and dependency or by Physicians who have been granted a waiver pursuant to the federal Drug Addiction Treatment Act of 2000 to prescribe Schedule III, IV and V narcotic medications for the treatment of opioid addiction during the Acute detoxification stage of treatment or during stages of rehabilitation.

Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year.

Harm Reduction Services (HRS): Effective July 1, 2018, HRS will be available to eligible recipients. HRS includes, but is not limited to, overdose prevention and response, and preventing transmission of HIV, Hepatitis B and C, and other illnesses in substance users. HRS is covered when recommended in writing by a physician or other licensed practitioner. Harm reduction services may only be provided by NYSDOH-authorized and waivered syringe exchange programs (SEPs) which are enrolled as Medicaid providers. Covered services include 1) Development of a Care Plan, 2) Individual and Group Supportive Counseling, 3) Medication Management and Treatment Adherence Counselling, and 4) Psychoeducation – Support Groups.

Covered in full

Plans may not may not require prior authorization for harm reduction services. After a 6 month period commencing July 1, 2018, plans may conduct concurrent review and retrospective review for medical necessity. Outside of the Plan’s service area, members may access services through out-of-network arrangements, but only with NYSDOH-authorized and waivered syringe exchange programs (SEPs).

Syringe exchange is not a covered Medicaid‐covered service.

Certain harm reduction services, such as syringe exchange, acupressure and overdose training will remain grant‐funded by the NYSDOH AIDS Institute and continue to be provided by these SEPs.







Coverage for outpatient, intensive outpatient, outpatient rehabilitation and opioid treatment at a participating OASAS-certified Facility is not subject to Preauthorization. For the first two (2) weeks of continuous treatment, not to exceed 14 visits, coverage is not subject to concurrent review if the OASAS-certified Facility notifies the Plan of both the start of treatment and the initial treatment plan within 48 hours. After the first two (2) weeks of continuous treatment, not to exceed 14 visits, the Plan may review the entire outpatient treatment to determine whether it is medically necessary. If any portion of



the outpatient treatment is denied as not medically necessary, the Member is only responsible for the in-network cost-sharing that would otherwise apply to outpatient treatment.

Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. $15 Copayment









Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. $0 No cost sharing by member





Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. Covered in full


















Covered in full

Plans may not may not require prior authorization for harm reduction services. After a 6 month period commencing July 1, 2018, plans may conduct concurrent review and retrospective review for medical necessity.

Outside of the Plan’s service area, members may access services through out-of-network arrangements, but only with NYSDOH-authorized and waivered syringe exchange programs (SEPs).









Covered in full

Plans may not may not require prior authorization for harm reduction services. After a 6 month period commencing July 1, 2018, plans may conduct concurrent review and retrospective review for medical necessity.

Outside of the Plan’s service area, members may access services through out-of-network arrangements, but only with NYSDOH-authorized and waivered syringe exchange programs (SEPs).







Coverage for outpatient, intensive outpatient, outpatient rehabilitation and opioid treatment at a participating OASAS-certified Facility is not subject to Preauthorization. For the first two (2) weeks of continuous treatment, not to exceed 14 visits, coverage is not subject to concurrent review if the OASAS-certified Facility notifies the Plan of both the start of treatment and the initial treatment plan within 48 hours. After the first two (2) weeks of continuous treatment, not to exceed 14 visits, the Plan may review the entire outpatient treatment to determine whether it is medically necessary. If any portion of the outpatient treatment is denied as not medically necessary, the Member is only responsible for the in-network cost-sharing that would otherwise apply

Cover up to 20 outpatient visits per Plan Year for family counseling. A family member will be deemed to be covered, for the purposes of this provision, so long as that family member: 1) identifies himself or herself as a family member of a person suffering from substance use disorder; and 2) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use disorder. Our payment for a family member therapy session will be the same



to outpatient treatment.


amount, regardless of the number of family members who attend the family therapy session. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)





Coverage for outpatient, intensive outpatient, outpatient rehabilitation and opioid treatment at a participating OASAS-certified Facility is not subject to Preauthorization. For the first two (2) weeks of continuous treatment, not to exceed 14 visits, coverage is not subject to concurrent review if the OASAS-certified Facility notifies the Plan of both the start of treatment and the initial treatment plan within 48 hours. After the first two (2) weeks of continuous treatment, not to exceed 14 visits, the Plan may review the entire outpatient treatment to determine whether it is medically necessary. If any portion of the outpatient treatment is denied as not medically necessary, the Member is only responsible for the in-network cost-sharing that would otherwise apply to outpatient treatment.


Family Coverage for Substance Abuse Services are not covered.















Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. 0% Coinsurance after deductible

Cover up to 20 outpatient visits per Plan Year for family counseling. A family member will be deemed to be covered, for the purposes of this provision, so long as that family member: 1) identifies himself or herself as a family member of a person suffering from substance use disorder; and 2) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use disorder. Our payment for a family member therapy session will be the same amount, regardless of the number of family members who attend the family



therapy session. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)



Beacon BronzePlus

Outpatient Substance Use Services relating to the diagnosis and treatment substance use disorder, but not limited to partial hospitalization program services, intensive outpatient program services, and medication-assisted treatment. Such Coverage is limited to Facilities in New York State that are certified by OASAS or licensed by OASAS as outpatient clinics or medically supervised ambulatory substance abuse programs, and, in other states, to those that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Coverage is also available in a professional office setting for outpatient substance use disorder services relating to the diagnosis and treatment of alcoholism, substance use and dependency or by Physicians who have been granted a waiver pursuant to the federal Drug Addiction Treatment Act of 2000 to prescribe Schedule III, IV and V narcotic medications for the treatment of opioid addiction during the Acute detoxification stage of treatment or during stages of rehabilitation.


Cover up to 20 outpatient visits per Plan Year for family counseling. (Plan Year: A calendar year ending on December 31 of each year.) A family member will be deemed to be covered, for the purposes of this provision, so long as that family member: 1) identifies himself or herself as a family member of a person suffering from substance use disorder; and 2) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use disorder. Our payment for a family member therapy session will be the same




amount, regardless of the number of family members who attend the family therapy session.



Beacon SilverPlus






Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. $30 Copayment after deductible

therapy session. (Plan Year: A calendar year ending on December 31 of each year.)



Beacon GoldPlus










Beacon PlatinumPlus












Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. $40 copayment per visit for individual or group therapy







Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. 0% OR 20% of the cost per visit for individual or group therapy





Beacon FIDA







N/A MetroPlus Managed Long Term Care (MLTC)


Enrollees must be allowed to self-refer for one (1) chemical dependence assessment from a MetroPlus’ participating provider per calendar year. NOT COVERED BENEFIT

N/A N/A







Cover up to 20 outpatient visits per Plan Year for family counseling. (Plan Year: A calendar year ending on December 31 of each year.) A family member will be deemed to be covered, for the purposes of this provision, so long as that family member: 1) identifies himself or herself as a family member of a person suffering from substance use disorder; and 2) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use disorder. Our payment for a family member therapy session will be the same amount, regardless of the number of family members who attend the family therapy session.





Beacon SilverPrime




Cover up to 20 outpatient visits per Plan Year for family counseling. A family member will be deemed to be covered, for the purposes of this provision, so long as that family member: 1) identifies himself or herself as a family member of a person suffering from substance use disorder; and 2) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use disorder. Our payment for a family member therapy session will be the same amount, regardless of the number of family members who attend the family therapy session. (Plan Year: A calendar year ending on December 31 of each year.)





Beacon GoldPrime







SUBSTANCE USE INPATIENT SERVICES

Beacon Medicaid

Inpatient Substance Use Services relating to the diagnosis and treatment of substance use disorder. This includes coverage for detoxification and rehabilitation services as a consequence of chemical use and/or substance use. Inpatient substance use services are limited to Facilities in New York State which are certified by the Office of Alcoholism and Substance Abuse Services (“OASAS”); and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Substance Use Services Inpatient detox services are covered. Coverage for residential treatment services is limited to OASAS-certified Facilities that provide services defined in 14 NYCRR 819.2(a)(1) and Part 817; and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs to provide the same level of treatment.

Specific services include, but are not limited to: - Medical management - Bio-psychosocial assessments



- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary Covered in full








- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $150 Copayment per hospital admission








- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $0 No cost sharing by member








































- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $0 Copayment





Specific services include, but are not limited to: - Medical management - Bio-psychosocial assessments - Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $300 copay per hospital admission, unlimited days per calendar year










- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $500 copay per hospital admission, unlimited days per calendar year








- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary 0% Coinsurance after deductible per hospital admission



Beacon BronzePlus








Beacon SilverPlus





- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $1500 Copayment after deductible per hospital admission



Beacon GoldPlus








Beacon PlatinumPlus



Plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Plan covers 90 days for each benefit period for an inpatient hospital stay. Plan also covers 60 "lifetime reserve days" These are "extra" days that plan will cover. If your hospital stay is longer



- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $500 Copayment per hospital admission

than 90 days, you can use these "extra" days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.

MENTAL HEALTH CARE

Inpatient Substance Use Services relating to the diagnosis and treatment of substance use disorder. This includes coverage for detoxification and rehabilitation services as a consequence of chemical use and/or substance use. Inpatient substance use services are limited to Facilities in New York State which are certified by the Office of Alcoholism and Substance Abuse Services (“OASAS”); and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Substance Use Services Inpatient detox services are covered. Coverage for residential treatment services is limited to OASAS-certified Facilities that provide services defined in 14 NYCRR 819.2(a)(1) and Part 817; and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited

Plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

PROVIDED BY BEACON



by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs to provide the same level of treatment.

Specific services include, but are not limited to: - Medical management - Bio-psychosocial assessments - Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $195 copayment for days 1 through 8 $0 (nothing) for days 9 through 90

Plan covers 90 days for each benefit period for an inpatient hospital stay. Plan also covers 60 "lifetime reserve days" These are "extra" days that plan will cover. If your hospital stay is longer than 90 days, you can use these "extra" days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.



Inpatient Substance Use Services relating to the diagnosis and treatment of substance use disorder. This includes coverage for detoxification and




rehabilitation services as a consequence of chemical use and/or substance use. Inpatient substance use services are limited to Facilities in New York State which are certified by the Office of Alcoholism and Substance Abuse Services (“OASAS”); and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Substance Use Services Inpatient detox services are covered. Coverage for residential treatment services is limited to OASAS-certified Facilities that provide services defined in 14 NYCRR 819.2(a)(1) and Part 817; and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs to provide the same level of treatment.

Specific services include, but are not limited to: - Medical management - Bio-psychosocial assessments - Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $0 OR $1340 deductible for days 1 through 60. $335 copayment per day for days 61 through 90




$670 copayment per day for 60 lifetime reserve days.



Beacon FIDA


Specific services include, but are not limited to: - Medical management - Bio-psychosocial assessments - Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary $0 Copayment






N/A MetroPlus Managed Long Term Care (MLTC)



N/A N/A

- Stabilization of medical psychiatric/psychological problems - Individual and group counseling - Level of care determinations - Referral and linkages to other services as necessary NOT COVERED BENEFIT











Beacon SilverPrime

Inpatient Substance Use Service s relating to the diagnosis and treatment of substance use disorder. This includes coverage for detoxification and rehabilitation services as a consequence of chemical use and/or substance use. Inpatient substance use services are limited to Facilities in New York State which are certified by the Office of Alcoholism and Substance Abuse Services (“OASAS”); and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs. Substance Use Services Inpatient detox services are covered. Coverage for residential treatment services is limited to OASAS-certified Facilities that provide services defined in 14 NYCRR 819.2(a)(1) and Part 817; and, in other states, to those Facilities that are licensed or certified by a similar state agency or which are accredited by the Joint Commission as alcoholism, substance abuse or chemical dependence treatment programs to provide the same level of treatment.


Cover up to 20 outpatient visits per Plan Year for family counseling. A family member will be deemed to be covered, for the purposes of this provision, so long as that family member: 1) identifies himself or herself as a family member of a person suffering from substance use disorder; and 2) is covered under the same family Certificate that covers the person receiving, or in need of, treatment for substance use disorder. Our payment for a family member




therapy session will be the same amount, regardless of the number of family members who attend the family therapy session. (Plan Year: A calendar year ending on December 31 of each year.)



Beacon GoldPrime






TRANSPORTATION EMERGENT

A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

Medicaid

Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services covered by Fee-For-Service Medicaid.

All emergency ambulance services are covered by Fee-For-Service Medicaid.

Services must be provided by an ambulance service issued a certificate to operate pursuant to Article 30, Section 3005 of the NYS Public Health Law.

Airborne emergency transportation requires

authorization

Airborne emergency transportation requires authorization

Services must be provided by an ambulance service issued a certificate to operate pursuant to Article 30,


A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888


Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) $75 Copayment

Section 3005 of the NYS Public Health Law.

Non-Participating Pre-Hospital Emergency Medical Services (Transportation via Ambulance resulting in Inpatient admission $75 Copayment


authorization


Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of

Services must be provided by an ambulance service issued a certificate to operate pursuant to Article 30, Section 3005 of the NYS Public Health


A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888


obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) $0 No cost sharing by member.

Law.

Non-Participating Pre-Hospital


authorization


Emergency Medical Services (Transportation via Ambulance resulting in Inpatient admission $0 No cost sharing by member.




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888


obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) Covered in Full.

Law.

Non-Participating Pre-Hospital


authorization


Emergency Medical Services (Transportation via Ambulance resulting in Inpatient admission Covered in Full


A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

Child Health Plus

Non-airborne hospital transportation services are covered for prompt evaluation and treatment of an emergency condition.

Coverage for non-airborne emergency transportation is based a prudent layperson standard.

All emergency ambulance services are covered. Transportation between two inpatient facilities is covered.


Non-emergent transportation services. Airborne transportation services.


authorization



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888


Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services All emergency ambulance services are covered. Covered in full.



authorization



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

HIV Special Needs

Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services All emergency ambulance services are covered. Covered in full.



authorization



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

MetroPlus Gold




authorization



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888





authorization



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888





authorization


Services must be provided by an ambulance service issued a certificate


A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888


Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) 0% Coinsurance after deductible

to operate pursuant to Article 30, Section 3005 of the NYS Public Health Law.

Non-Participating Pre-Hospital Emergency Medical Services (Transportation via Ambulance resulting in Inpatient admission 0% Coinsurance after deductible


authorization




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

BronzePlus





authorization




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

SilverPlus

Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) $150 Copayment after deductible


Non-Participating Pre-Hospital Emergency Medical Services (Transportation via Ambulance resulting in Inpatient admission $150 Copayment after deductible


authorization




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

GoldPlus






A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

PlatinumPlus





authorization


Services must be provided by an ambulance service issued a certificate to operate pursuant to Article 30,


A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

Medicare Platinum

Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) $100 Copayment (copayment waived if admitted to the hospital directly from Emergency Department)

Section 3005 of the NYS Public Health Law.

Non-Participating Pre-Hospital Emergency Medical Services


authorization


(Transportation via Ambulance resulting in Inpatient admission $100 Copayment (copayment waived if admitted to the hospital directly from Emergency Department)




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

Medicare Advantage

obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) 0% OR 20% of cost (if admitted fees waived)

Law.

Non-Participating Pre-Hospital Emergency Medical Services


authorization


(Transportation via Ambulance resulting in Inpatient admission 0% OR 20% of cost (if admitted fees waived)



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

FIDA

Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) $0 No cost to member


Non-Participating Pre-Hospital Emergency Medical Services (Transportation via Ambulance resulting in Inpatient admission $0 No cost to member


authorization


TRANSPORTATION EMERGENT N/A MetroPlus Managed


Emergency Transportation by an ambulance service, including air ambulance is covered for purposes of providing transportation for the purpose of obtaining hospital services for an enrollee who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services resulting in hospital inpatient admission (Pre-Hospital Emergency Medical Services) NO COVERED BENEFIT


N/A N/A



A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

BronzePlus HSA





authorization




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

SilverPrime





authorization




A0422,A0424-A0425,A0427,A0429,A0433,A0434 A0430-A0431,A0435,A0436,A0888

GoldPrime




TRANSPORTATION NON-EMERGENT A0080-A0210 Medicaid

Non-Emergent Transportatio n expenses are covered when transportation is essential in order for a member to obtain necessary medical care services and covered by Fee-For-Service Medicaid Covers transportation services by ambulance, ambulette or invalid coach, taxicab, livery, public transportation or other means appropriate to the member's medical condition; and a transportation attendant to accompany the member, if necessary. Such services may include the transportation attendant's transportation, meals, lodging and salary. For members with disabilities, the method of transportation must reasonably accommodate their needs, taking into account the severity and nature of the disability.

No salary will be paid to a transportation attendant who is a family member of the enrollee. LogistiCare at 1‐877‐564‐5922 LogistiCare at 1‐877‐564‐5923

We do not cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab.

Non-Emergency (ambulance) Transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities Coverage for air ambulance related to an Emergency Condition or air

when the transport is any of the following: ambulance related to non-

TRANSPORTATION NON-EMERGENT A0080-A0210 Essential Plan 1

Non-Aliessa

--From a non-participating Hospital to a participating Hospital; --To a Hospital that provides a higher level of care that was not available at the original Hospital; --To a more cost-effective Acute care Facility; or

emergency transportation is provided when Your medical condition is such that transportation by land

No salary will be paid to a transportation attendant who is a family member of the enrollee. YES YES

--From an Acute care Facility to a sub-Acute setting. $75 Copayment

ambulance is not appropriate; and Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles (e.g., heavy traffic) prevent Your timely transfer to the nearest Hospital with appropriate facilities.




TRANSPORTATION NON-EMERGENT A0080-A0210 Essential Plan 2

Non-Aliessa



No salary will be paid to a transportation attendant who is a family member of the enrollee. YES



TRANSPORTATION NON-EMERGENT A0080-A0210 Essential Plan 3/4

Aliessa

Non-Emergency (ambulance) Transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: --From a non-participating Hospital to a participating Hospital; --To a Hospital that provides a higher level of care that was not available at the original Hospital; --To a more cost-effective Acute care Facility; or

We do not cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land




TRANSPORTATION NON-EMERGENT N/A Child Health Plus NOT COVERED BENEFIT N/A N/A

TRANSPORTATION NON-EMERGENT A0080-A0210 MetroPlus Enhanced

(HARP)

Non-emergent transportation expenses are covered when transportation is essential in order for a member to obtain necessary medical care services covered by Fee-For-Service Medicaid. Covers transportation services by ambulance, ambulette or invalid coach, taxicab, livery, public transportation or other means appropriate to the member's medical condition; and a transportation attendant to accompany the member, if necessary. Such services may include the transportation attendant's transportation, meals, lodging and salary. For members with disabilities, the method of transportation must reasonably accommodate their needs, taking into account the severity and nature of the disability. Covered in full

LogistiCare at 1-877-564-5922 . If possible, you or your provider should call LogistiCare at least 3 days before your medical appointment and provide your Medicaid identification number.

No salary will be paid to a transportation attendant who is a family member of the enrollee. LogistiCare at 1-877-564-5922 LogistiCare at 1-877-564-5922

TRANSPORTATION NON-EMERGENT A0080-A0210 HIV Special Needs

Non-emergent transportation expenses are covered when transportation is essential in order for a member to obtain necessary medical care services covered by Fee-For-Service Medicaid. Covers transportation services by ambulance, ambulette or invalid coach, taxicab, livery, public transportation or other means appropriate to the member's medical condition; and a transportation attendant to accompany the member, if necessary. Such services may include the transportation attendant's transportation, meals, lodging and salary. For members with disabilities, the method of transportation must reasonably accommodate their needs, taking into account the severity and nature of the disability. Covered in full

No salary will be paid to a transportation attendant who is a family member of the enrollee. LogistiCare at 1-877-564-5922 LogistiCare at 1-877-564-5922

TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 MetroPlus Gold

Non-Emergency (ambulance) Transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: --From a non-participating Hospital to a participating Hospital; --To a Hospital that provides a higher level of care that was not available at the original Hospital; --To a more cost-effective Acute care Facility; or --From an Acute care Facility to a sub-Acute setting. $0 Copayment

We do not cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land ambulance is not appropriate; and

No salary will be paid to a transportation attendant who is a family member of the enrollee.

YES YES

Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles

TRANSPORTATION NON-EMERGENT N/A MetroPlus GoldCare I

Non-Emergency (ambulance) Transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: --From a non-participating Hospital to a participating Hospital; --To a Hospital that provides a higher level of care that was not available at the original Hospital; --To a more cost-effective Acute care Facility; or --From an Acute care Facility to a sub-Acute setting. NOT COVERED BENEFIT

We do not cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land ambulance is not appropriate; and

No salary will be paid to a transportation attendant who is a family member of the enrollee.

N/A

Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles We do not cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance

Non-Emergency (ambulance) Transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities transportation such as ambulette, van or taxi cab.

when the transport is any of the following: Coverage for air ambulance related

TRANSPORTATION NON-EMERGENT N/A MetroPlus GoldCare II


to an Emergency Condition or air ambulance related to non-emergency transportation is provided

No salary will be paid to a transportation attendant who is a family member of the enrollee. N/A N/A

--From an Acute care Facility to a sub-Acute setting. NOT COVERED BENEFIT

when Your medical condition is such that transportation by land ambulance is not appropriate; and Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or




TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 MedPlus

Catastrophic

- From a non-participating Hospital to a participating Hospital; -To a Hospital that provides a higher level of care that was not available at the original Hospital; -To a more cost-effective Acute care Facility; or



- From an Acute care Facility to a sub-Acute setting. Non-Emergency Ambulance Services 0% Coinsurance after deductible


TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 BronzePlus

Non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: - From a non-participating Hospital to a participating Hospital; -To a Hospital that provides a higher level of care that was not available at the original Hospital; -To a more cost-effective Acute care Facility; or - From an Acute care Facility to a sub-Acute setting. Non-Emergency Ambulance Services

We do not Cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land ambulance is not appropriate; and


50% Coinsurance after deductible Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles (e.g., heavy traffic) prevent Your timely transfer to the nearest Hospital with appropriate facilities.

TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 SilverPlus




$150 Copayment after deductible Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles (e.g., heavy traffic) prevent Your timely transfer to the nearest Hospital with appropriate facilities.

TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 GoldPlus

Non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: - From a non-participating Hospital to a participating Hospital; -To a Hospital that provides a higher level of care that was not available at the original Hospital; -To a more cost-effective Acute care Facility; or

We do not Cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land


- From an Acute care Facility to a sub-Acute setting. Non-Emergency Ambulance Services $150 Copayment after deductible


TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 PlatinumPlus

Non-Emergency (ambulance) Transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: - From a non-participating Hospital to a participating Hospital; -To a Hospital that provides a higher level of care that was not available at the original Hospital; -To a more cost-effective Acute care Facility; or - From an Acute care Facility to a sub-Acute setting. Non-Emergency Ambulance Services



$100 Copayment Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles (e.g., heavy traffic) prevent Your timely transfer to the nearest Hospital with appropriate facilities.

TRANSPORTATION NON-EMERGENT A0080-A0210 Medicare Platinum

Non-emergency transportation by ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by ambulance is medically required.

$100 copayment

N/A N/A

TRANSPORTATION NON-EMERGENT A0080-A0210 Medicare Advantage

Non-Emergent Transportation expenses are covered when transportation is essential in order for a member to obtain necessary medical care services and covered by Fee-For-Service Medicaid Covers transportation services by ambulance, ambulette or invalid coach, taxicab, livery, public transportation or other means appropriate to the member's medical condition; and a transportation attendant to accompany the member, if necessary. Such services may include the transportation attendant's transportation, meals, lodging and salary. For members with disabilities, the method of transportation must reasonably accommodate their needs, taking into account the severity and nature of the disability. COVERED BY FEE FOR SERVICE MEDICAID

LogistiCare at 1-877-564-5922 LogistiCare at 1-877-564-5923

TRANSPORTATION NON-EMERGENT A0080-A0210 FIDA

Non-Emergent Transportation expenses are covered when transportation is essential in order for a member to obtain necessary medical care services and covered by Fee-For-Service Medicaid. Includes Social day care transportation. Covers transportation services by ambulance, ambulette or invalid coach, taxicab, livery, public transportation or other means appropriate to the member's medical condition; and a transportation attendant to accompany the member, if necessary. Such services may include the transportation attendant's transportation, meals, lodging and salary. For members with disabilities, the method of transportation must reasonably accommodate their needs, taking into account the severity and nature of the disability. $0 No cost to member

Customer Service Sets Up Non-Emergent Transportation


TRANSPORTATION NON-EMERGENT A0080-A0210 MetroPlus Managed


Non-Emergent Transportation expenses are covered when transportation is essential in order for a member to obtain necessary medical care services and covered by Fee-For-Service Medicaid Covers transportation services by ambulance, ambulette or invalid coach, taxicab, livery, public transportation or other means appropriate to the member's medical condition; and a transportation attendant to accompany the member, if necessary. Such services may include the transportation attendant's transportation, meals, lodging and salary. For members with disabilities, the method of transportation must reasonably accommodate their needs, taking into account the severity and nature of the disability. Covered in full



TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 BronzePlus HSA



YES YES

50% Coinsurance after deductible Your medical condition requires immediate and rapid ambulance transportation that cannot be provided by land ambulance; and one (1) of the following is met: o The point of pick-up is inaccessible by land vehicle; or o Great distances or other obstacles (e.g., heavy traffic) prevent Your timely transfer to the nearest Hospital with appropriate facilities.

TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 SilverPrime




authorization


TRANSPORTATION NON-EMERGENT A0425-A0428, A0130 GoldPrime

Non-emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance, as appropriate) between Facilities when the transport is any of the following: - From a non-participating Hospital to a participating Hospital; -To a Hospital that provides a higher level of care that was not available at the original Hospital; -To a more cost-effective Acute care Facility; or

We do not Cover travel or transportation expenses, unless connected to an Emergency Condition or due to a Facility transfer approved by Us, even though prescribed by a Physician. We do not Cover non-ambulance transportation such as ambulette, van or taxi cab. Coverage for air ambulance related to an Emergency Condition or air ambulance related to non-emergency transportation is provided when Your medical condition is such that transportation by land


- From an Acute care Facility to a sub-Acute setting. Non-Emergency Ambulance Services $150 Copayment after deductible


PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK Medicaid

Covered by CVS/Caremark. Including pharmaceuticals and medical supplies routinely furnished or administered as part of a clinic or office visit. - Prescription drugs - Over-the-counter medicines - Insulin and diabetic supplies - Smoking cessation agents, including OTC products - Hearing aid batteries - Emergency Contraception (6 per calendar year) - Medical and surgical supplies - Contraceptive drugs or devices -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene.

Brand Name Prescription Drugs $3.00/$1.00 Copayment Generic Prescription Drugs $1.00 Copayment Over the counter drugs, such as for smoking cessation and diabetes $0.50 Copayment

One (1) copayment charge for each new prescription and each refill. No copayment for -Drugs to treat mental illness (psychotropic) and tuberculosis. - Contraceptive drugs or devices - Medicine to treat breast cancer.

If you have a co-pay, you are responsible for a maximum of $200 each calendar year.

Authorization by CVS/Caremark is required for Certain

Classifications of Medications

Authorization by CVS/Caremark is required for Certain Classifications of

Medications

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK Essential Plan 1

Non-Aliessa

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy and 30 day supply Mail Order Tier 1 $6 Copayment Tier 2 $15 Copayment Tier 3 $30 Copayment Up to a 90-day supply for Maintenance Drugs Tier 1 $18 Copayment Tier 2 $45 Copayment

Benefit administered by CVS/Caremark with Formulary restrictions.

No copayment for - Contraceptive drugs or devices - Medicine to treat breast cancer

The Prescription Drug Rider does not




Medications Tier 3 $90 Copayment

Mail Order Pharmacy Up to a 90-day supply Tier 1 $15 Copayment Tier 2 $37.50 Copayment Tier 3 $75 Copayment

.Enteral Formulas- Enteral formulas that are medically necessary Tier 1 $6 Copayment Tier 2 $15 Copayment Tier 3 $30 Copayment

cover: - Any drug or device which does not require a prescription, even if a prescription is written. - Replacements of drugs or devices resulting from loss, theft or breakage.

PRESCRIPTION DRUGS


Non-Aliessa

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy and 30 day supply Mail Order Tier 1 $1 Copayment Tier 2 $3 Copayment Tier 3 $3 Copayment Up to a 90-day supply for Maintenance Drugs Tier 1 $3 Copayment Tier 2 $9 Copayment







Medications Tier 3 $9 Copayment

Mail Order Pharmacy Up to a 90-day supply Tier 1 $2.50 Copayment Tier 2 $7.50 Copayment Tier 3 $7.50 Copayment

Enteral Formulas- Enteral formulas that are medically necessary Tier 1 $1 Copayment Tier 2 $3 Copayment Tier 3 $3 Copayment


PRESCRIPTION DRUGS


Aliessa

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy and 30 supply Mail Order Tier 1 $1 Copayment Tier 2 $3 Copayment Tier 3 $3 Copayment Up to a 90-day supply for Maintenance Drugs Tier 1 $3 Copayment Tier 2 $9 Copayment Tier 3 $9 Copayment



The Prescription Drug Rider does not cover:




Medications

Mail Order Pharmacy Up to a 90-day supply Tier 1 $2.50 Copayment Tier 2 $7.50 Copayment Tier 3 $7.50 Copayment

- Any drug or device which does not require a prescription, even if a prescription is written. - Replacements of drugs or devices resulting from loss, theft or breakage.

.Enteral Formulas- Enteral formulas that are medically necessary Tier 1 $1 Copayment Tier 2 $3 Copayment Tier 3 $3 Copayment NON-PRESCRIPTION DRUGS $0.50 copayment

PRESCRIPTION DRUGS


Aliessa

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy and 30 day supply Mail Order Tier 1 $0 Copayment Tier 2 $0 Copayment Tier 3 $0 Copayment

Up to a 90-day supply for Maintenance Drugs * Tier 1 $0 Copayment Tier 2 $0 Copayment Tier 3 $0 Copayment



The Prescription Drug Rider does not cover: - Any drug or device which does not require a prescription, even if a




Medications

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $0 Copayment Tier 2 $0 Copayment Tier 3 $0 Copayment Enteral Formulas- Enteral formulas that are medically necessary*

prescription is written. - Replacements of drugs or devices resulting from loss, theft or breakage. - All compounded Prescription Drugs over $250 require Your Provider to obtain Preauthorization.

Tier 1 $0 Copayment Tier 2 $0 Copayment Tier 3 $0 Copayment *See Benefit Description NON-PRESCRIPTION DRUGS $0

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK Child Health Plus

Covered by CVS/Caremark. Prescription drugs must be medically necessary and are subject to formulary restrictions. Prescription drugs may include, but are not limited to: - Peak Flow Meters - Family planning or contraceptive medications or devices - All medications used for preventive and therapeutic purposes - Modified solid food products that are low-protein or that contain modified protein are covered for individuals with certain inherited diseases of amino acid and organic acid metabolism. - Enteral formulas for home use.

Note: Benefit administered by CVS/Caremark with Formulary restrictions.

Benefit administered by CVS/Caremark with Formulary restrictions. - Enteral formulas for the treatment of specific diseases shall be distinguished from nutritional supplements taken electively. - Coverage for modified solid food products shall not exceed $2500 per calendar year.

Vitamins are not covered except when necessary to treat a diagnosed illness or condition. - Prescription drugs and biologicals that are furnished for the purpose of causing or assisting in causing the death, suicide, euthanasia or mercy killing of a person. - Erectile dysfunction drugs are not covered. - Ostomy supplies are not covered.



Enteral formulas must be approved by CVS/Caremark.


Medications

Enteral formulas must be approved by CVS/Caremark.

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK MetroPlus Enhanced

(HARP)

Covered by CVS/Caremark. Including pharmaceuticals and medical supplies routinely furnished or administered as part of a clinic or office visit. - Prescription drugs - Over-the-counter medicines - Insulin and diabetic supplies - Smoking cessation agents, including OTC products - Hearing aid batteries - Emergency Contraception (6 per calendar year) - Medical and surgical supplies - Contraceptive drugs or devices - Copayment do not apply

One (1) copayment charge for each new prescription and each refill.

No copayment for -Drugs to treat mental illness (psychotropic) and tuberculosis. - Contraceptive drugs or devices - Medicine to treat breast cancer


authorization


-Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply.



PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK HIV Special Needs

Covered by CVS/Caremark. Including pharmaceuticals and medical supplies routinely furnished or administered as part of a clinic or office visit. - Prescription drugs - Over-the-counter medicines - Insulin and diabetic supplies - Smoking cessation agents, including OTC products - Hearing aid batteries - Emergency Contraception (6 per calendar year) - Medical and surgical supplies - Contraceptive drugs or devices Copayments do not apply

One (1) copayment charge for each new prescription and each refill.

No copayment for -Drugs to treat mental illness (psychotropic) and tuberculosis. - Contraceptive drugs or devices - Medicine to treat breast cancer


authorization


-Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply.



PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK MetroPlus Gold

FOR ALL MEMBERS WITH OR WITHOUT PRESCRIPTION DRUG RIDER: - All medications and supplies for the treatment of diabetes are covered - Injectable drugs administered in a doctor’s office are covered -Coverage of Statins (drugs that reduce fat and cholesterol in the blood) in network, Copayments do not apply. - Medicines used to treat substance-use disorders. This includes medicines usually prescribed for opioid addiction and dependence.

FOR MEMBERS WITH OPTIONAL PRESCRIPTION DRUG RIDER: Coverage: - Benefit administered by CVS/Caremark with Formulary restrictions. - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy. - Full coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Enteral formulas that are medically necessary. - Modified solid food products that are low protein or which contain modified protein are covered. These products cannot exceed $2500 per member per calendar year. - Bone mineral density prescription drugs. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Co-payments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply.


No copayment for - Contraceptive drugs or devices - Medicine to treat breast cancer - Statin coverage- Adults between 40 to 75 without a history of cardiovascular disease and have high risk morbidities such as diabetes, smoking and/or hypertension.


authorization


Retail Pharmacy Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy or Mail Order Tier 1 $5 Copayment Tier 2 $35 Copayment Tier 3 $70 Copayment Mail Order Pharmacy* Up to a 90-day supply Tier 1 $10 Copayment

The Prescription Drug Rider does not cover: - Any drug or device which does not require a prescription, even if a prescription is written. - Replacements of drugs or devices resulting from loss, theft or breakage.

Tier 2 $70 Copayment Tier 3 $140 Copayment Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $5 Copayment Tier 2 $35 Copayment Tier 3 $70 Copayment

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK MetroPlus GoldCare I

All medications and supplies for the treatment of diabetes are covered Injectable drugs administered in a doctor’s office are covered

Benefit administered by CVS/Caremark with Formulary restrictions. Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy. Full coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. Enteral formulas that are medically necessary. Modified solid food products that are low protein or which contain modified protein are covered. These products cannot exceed $2500 per member per calendar year. Bone mineral density prescription drugs. Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply.

Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 $25 Copayment Tier 2 $50 Copayment Tier 3 $75 Copayment Mail Order Pharmacy* Up to a 90-day supply Tier 1 $62.50 Copayment Tier 2 $125 Copayment





authorization


Tier 3 $187.50 Copayment Enteral Formulas-Enteral formulas that are medically necessary* Tier 1 $25 Copayment Tier 2 $50 Copayment Tier 3 $75 Copayment

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK MetroPlus GoldCare II

All medications and supplies for the treatment of diabetes are covered Injectable drugs administered in a doctor’s office are covered

Benefit administered by CVS/Caremark with Formulary restrictions. Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy. Full coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. Enteral formulas that are medically necessary. Modified solid food products that are low protein or which contain modified protein are covered. These products cannot exceed $2500 per member per calendar year. Bone mineral density prescription drugs. Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply.

Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 $25 Copayment Tier 2 $50 Copayment Tier 3 $75 Copayment Mail Order Pharmacy* Up to a 90-day supply Tier 1 $62.50 Copayment Tier 2 $125 Copayment





authorization


Tier 3 $187.50 Copayment Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $25 Copayment Tier 2 $50 Copayment Tier 3 $75 Copayment

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK MedPlus

Catastrophic

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 0% Coinsurance after deductible Tier 2 0% Coinsurance after deductible Tier 3 0% Coinsurance after deductible





authorization


Mail Order Pharmacy* Up to a 90-day supply Tier 1 0% Coinsurance after deductible Tier 2 0% Coinsurance after deductible Tier 3 0% Coinsurance after deductible

Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 0% Coinsurance after deductible Tier 2 0% Coinsurance after deductible Tier 3 0% Coinsurance after deductible


PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK BronzePlus

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 $10 Copayment after deductible Tier 2 $35 Copayment after deductible Tier 3 $70 Copayment after deductible

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $25 Copayment after deductible Tier 2 $87.50 Copayment after deductible Tier 3 $175 Copayment after deductible Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $10 Coinsurance after deductible




Tier 2 $35 Coinsurance after deductible Tier 3 $70 Coinsurance after deductible

Prescription Drugs Administered in Outpatient Facilities 50% Coinsurance after Deductible

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK SilverPlus

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy or Mail Order Tier 1 $10 Copayment not subject to Deductible Tier 2 $35 Copayment not subject to Deductible Tier 3 $70 Copayment not subject to Deductible

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $25 Copayment not subject to Deductible Tier 2 $87.50 Copayment not subject to Deductible Tier 3 $175 Copayment not subject to Deductible

Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $10 Copayment not subject to Deductible Tier 2 $35 Copayment not subject to Deductible Tier 3 $70 Copayment not subject to Deductible




Prescription Drugs Administered in Office or Outpatient Facilities $30 Copayment after Deductible

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK GoldPlus

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 $10 Copayment not subject to Deductible Tier 2 $35 Copayment not subject to Deductible Tier 3 $70 Copayment not subject to Deductible

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $25 Copayment not subject to Deductible Tier 2 $87.50 Copayment not subject to Deductible Tier 3 $175 Copayment not subject to Deductible





Prescription Drugs Administered in Outpatient Facilities $25 Copayment after Deductible

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK PlatinumPlus

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply. -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy or Mail Order Tier 1 $10 Copayment Tier 2 $30 Copayment Tier 3 $60 Copayment

Mail Order Pharmacy*





authorization


Up to a 90-day supply Tier 1 $25 Copayment Tier 2 $75 Copayment Tier 3 $150 Copayment

Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $10 Copayment Tier 2 $30 Copayment Tier 3 $60 Copayment

Prescription Drugs Administered in Outpatient Facilities $15 Copayment


PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK Medicare Platinum

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments apply Part B 20% copayment Part D & (Supplemental Coverage if any) $405 Deductible Tier 1 Generic Drugs (including brand drugs treated as generic) 25% Co-insurance after you pay yearly deductible Tier 2 All other drugs 25% Co-insurance after you pay yearly deductible

Coverage Gap Stage You remain in Stage 3 until your costs total $5,000, which is the end of the Coverage Gap. Tier 1 44% co-insurance Tier 2 35% co-insurance

Catastrophic Coverage Stage Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the year. Tier 1 The greater of 5% of the cost or a $3.35 copay Tier 2 The greater of 5% of the cost or a $8.35 copay




You remain in Coverage Gap Stage until your costs total $4,950.

Catastrophic Coverage Stage, you will stay in this payment stage until the end of the year.


authorization


PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK Medicare Advantage

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments apply Part B 0% OR 20% cost Part D If you receive “Extra Help” to pay your prescription drugs, your deductible amount will be either $0 or $82

Cost-Sharing Tier 1 (generic drugs, including brand drugs treated as generics) $0 copayment OR $1.25 copayment OR $3.35 copayment, OR up to 15% Coinsurance

Benefit administered by CVS/Caremark with Formulary restrictions. The Prescription Drug Rider does not cover: - Any drug or device which does not require a prescription, even if a prescription is written. - Replacements of drugs or devices resulting from loss, theft or breakage.


authorization


Cost-Sharing Tier 2 (For all other drugs) $0 copayment OR $3.70 copayment OR $8.35 copayment OR up to 15% Coinsurance

Depending on your level of Medicaid eligibility, once your total drug costs have reached $3,700, you will move to the Coverage Gap Stage. Or, once your yearly out-of-pocket costs reach $4,950, you will move to the next stage

Catastrophic Coverage Stage (Once your yearly out of- pocket costs reach $5,000, you will move to the next stage, the Catastrophic Coverage stage. Once you are at the Catastrophic Coverage Stage, you will stay at this payment stage until the end of the year) Tier 1 0 or $3.35, depending on your level of Extra Help Tier 2 $0 or $8.35, depending on your level of Extra Help.

(the Catastrophic Coverage stage)

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK FIDA

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Part B $0 Copayment Part D Medicaid pays copays

Medication therapy management (MTM) services - $0 copay






Medications

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK N/A MetroPlus Managed


FOR ALL MEMBERS: Benefit administered by CVS/Caremark : - All supplies for the treatment of diabetes are covered copayments apply

All Other Prescription Drugs and Supplies not covered.

Benefit administered by CVS/Caremark with Formulary restrictions. The Prescription Drug Rider does not cover: - Any drug or device which does not require a prescription, even if a prescription is written. - Replacements of drugs or devices resulting from loss, theft or breakage.

N/A N/A

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK BronzePlus HSA

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 $10 Copayment after deductible Tier 2 $35 Copayment after deductible Tier 3 $70 Copayment after deductible

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $25 Copayment after deductible Tier 2 $87.50 Copayment after deductible Tier 3 $175 Copayment after deductible Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $10 Coinsurance after deductible




Tier 2 $35 Coinsurance after deductible Tier 3 $70 Coinsurance after deductible

Prescription Drugs Administered in Outpatient Facilities 50% Coinsurance after Deductible

PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK SilverPrime

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy or mail order Tier 1 $10 Copayment not subject to deductible Tier 2 $40 Copayment not subject to deductible Tier 3 $80 Copayment not subject to deductible

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $25 Copayment not subject to deductible Tier 2 $100 Copayment not subject to deductible Tier 3 $200 Copayment not subject to deductible e

Enteral Formulas- Enteral formulas that are medically necessary* Tier 1 $10 Copayment not subject to deductible Tier 2 $40 Copayment not subject to deductible Tier 3 $80 Copayment not subject to deductible





PRESCRIPTION DRUGS

PROVIDED BY CVS/CAREMARK PROVIDED BY CVS/CAREMARK GoldPrime

FOR ALL MEMBERS: Benefit administered by CVS/Caremark with Formulary restrictions. - All medications and supplies for the treatment of diabetes are covered copayments apply - Injectable drugs administered in a doctor’s office are covered copayments apply - Coverage of prescription drugs, with a prescription, that are purchased through MetroPlus’ network of participating pharmacies. - Coverage is provided for prescription contraceptive drugs or devices approved by the FDA or generic equivalents approved by the FDA. Copayments do not apply -Medicine to lower breast cancer risk for women at increased risk for breast cancer such as tamoxifen or raloxifene. Copayments do not apply. Retail Pharmacy - Thirty (30) day supply of prescription drugs purchased at a participating retail pharmacy Tier 1 $10 Copayment not subject to Deductible Tier 2 $40 Copayment not subject to Deductible Tier 3 $80 Copayment not subject to Deductible

Mail Order Pharmacy* Up to a 90-day supply Tier 1 $25 Copayment not subject to Deductible Tier 2 $100 Copayment not subject to Deductible Tier 3 $200 Copayment not subject to Deductible






Durable Medical Equipment means devices and equipment (other than medical/surgical supplies, enteral formula, and prosthetic or orthotic appliances) ordered by a practitioner for the treatment of a specific medical condition which: (1) Can withstand repeated use for a protracted period of time; (2) Are primarily and customarily used for medical purposes; (3) Are generally not useful in the absence of illness or injury; and (4) Are usually not fitted, designed or fashioned for a particular person's use

DME includes hospital beds and accessories, oxygen and oxygen supplies, pressure pads, volume ventilators, therapeutic ventilators, nebulizers and other


Wigs are covered only for medically induced hair loss.

EXCLUSION: - Standard household items (e.g. air conditioners) - Disposable medical supplies and enteral formula are covered by Medicaid Fee For Service with a provider's order.

DURABLE MEDICAL EQUIPMENT (DME)

DME-E0100-E8002, Wheelchairs-K0001-K0903,Orthotics/prosthetics/hearing

aids services L0112-L9900 Medicaid

equipment for respiratory care, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts, nutrition infusion pumps, ambulatory infusion pumps and other miscellaneous DME such as peak flow meters.

Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity

Equipment and supplies can only be obtained from a contracted vendor. Prosthetic Devices: External: One (1) prosthetic device per limb, per lifetime and the cost and repair

-Hearing Aids Batteries are covered as part of the prescription benefit (i.e. Medicaid Fee-For-Service)

Items listed in NY State Medicaid Program Description & Coverage Guidelines, Sections 4.1 and 4.2 (www.emedny.org) are not covered by MetroPlus, but

YES-Except Supplies Y-ALL OUT OF NETWORK

evaluations and hearing aid repairs . Cochlear Implants included. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Covered in full

and replacement of the prosthetic devices and its parts.

Internal: included as part of inpatient hospitals services.

covered by Medicaid Fee For Service.

The Omnipod Insulin Management System is not covered.







aids services L0112-L9900


equipment for respiratory care, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts, nutrition infusion pumps, ambulatory infusion pumps and other miscellaneous DME such as peak flow meters. Medical Supplies: Ostomy supplies 5% Coinsurance Diabetic supplies $15 Copayment Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs. Cochlear Implants included. 5% Cost Sharing Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included 5% coinsurance member responsibility for prosthetics Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Orthotics Services Are Not Covered. Member is responsible for all costs. Orthopedic Footwear Services Are Not Covered. Member is responsible for all costs.

Breast Pumps - covered in full Assistive Communication Devices for Autism Spectrum Disorder $15 copayment

Equipment and supplies can only be obtained from a contracted vendor.

External Hearing Aids Once Every 3 Years Cochlear Implants One Per Ear Per lifetime

Prosthetic Devices: External: One (1) prosthetic device per limb, per lifetime and the cost and repair and replacement of the prosthetic devices and its parts. Internal: included as part of inpatient hospitals services cost sharing.

EXCLUSION: - Standard household items (e.g. air conditioners)



DME includes hospital beds and accessories, oxygen and oxygen supplies, pressure pads, volume ventilators, therapeutic ventilators, nebulizers and other equipment for respiratory care, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts,



Equipment and supplies can only be obtained from a contracted vendor. EXCLUSION:

- Standard household items (e.g. air conditioners)


DME-E0100-E8002, Wheelchairs-K0001-K0903,Orthotics/prosthetics-/hearing



nutrition infusion pumps, ambulatory infusion pumps and other miscellaneous DME such as peak flow meters.

Medical Supplies Diabetic supplies , Ostomy supplies

External Hearing Aids Once Every 3 Years Cochlear Implants One Per Ear Per


Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs . Cochlear Implants included. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. $0 No cost sharing by member

lifetime













Medical Supplies Diabetic supplies, Ostomy supplies



Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs . Cochlear Implants included. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Covered in full

lifetime





Wigs are covered only for medically induced hair loss. EXCLUSION:



aids services L0112-L9900 Child Health Plus




































aids services L0112-L9900 HIV Special Needs

















aids services L0112-L9900 MetroPlus Gold

DME includes hospital beds and accessories, oxygen and oxygen supplies, pressure pads, volume ventilators, therapeutic ventilators, nebulizers and other equipment for respiratory care, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts, nutrition infusion pumps, ambulatory infusion pumps and other miscellaneous DME such as peak flow meters.

Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

$0 No Cost sharing by member








Non-Participating Provider Services Are Not Covered EXCLUSION:


DME-E0100-E8002, Wheelchairs-K0001-K0903,Orthotics/hearing aids services

L0112-L9900 MetroPlus GoldCare I


Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aids- Not Covered Cochlear Implant - 20% Coinsurance



- Standard household items (e.g. air conditioners) - Hearing Aids - Prosthetic devices - Shoe Inserts YES-Except Supplies Y-ALL OUT OF NETWORK

Prosthetics - 20% Coinsurance Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Shoe inserts are not covered. 20% Coinsurance for DME

Diabetic Equipment, Supplies and Insulin (30-day supply) - $20 Copayment per month

Breast Pumps -covered in full

Cochlear Implants One Per Ear Per lifetime



Non-Participating Provider Services Are Not Covered EXCLUSION:


DME-E0100-E8002, Wheelchairs-K0001-K0903,Orthotics/hearing aids services

L0112-L9900 MetroPlus GoldCare II


Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aids-Not Covered Cochlear Implant -20% Coinsurance



- Standard household items (e.g. air conditioners) - Hearing Aids - Prosthetic devices - Shoe Inserts YES-Except Supplies Y-ALL OUT OF NETWORK

Prosthetics - 20% Coinsurance Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Shoe inserts are not covered.

20% Coinsurance for DME

Diabetic Equipment, Supplies and Insulin (30-day supply) - $20 Copayment per month Breast Pumps - covered in full

Cochlear Implants One Per Ear Per lifetime









Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

0% Coinsurance after deductible













DME-E0100-E8002, Wheelchairs-K0001-K0903 Orthotics/prosthetics/ hearing

aids services L0112-L9900 BronzePlus Medical Supplies Diabetic supplies, Ostomy supplies

Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.


Breast Pumps - covered in full












aids services L0112-L9900 SilverPlus

Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs ..



Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. 30% Coinsurance after deductible

Diabetic Equipment, Supplies and (30-day supply) $30 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder - $30 Copayment after Deductible Breast Pumps - covered in full

lifetime










aids services L0112-L9900 GoldPlus

Medical Supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs ..




Breast Pumps - covered in full Diabetic Equipment, Supplies and Insulin (30-day supply) $25 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder $25 Copayment after Deductible

lifetime










aids services L0112-L9900 PlatinumPlus




Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. 10% Coinsurance

Breast Pumps -covered in full Diabetic Equipment, Supplies and Insulin (30-day supply) $15 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder $15 Copayment after Deductible

lifetime



Equipment and supplies can only be obtained from a contracted vendor. Non-Participating Provider Services Are Not Covered



aids services L0112-L9900 Medicare Platinum


Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs . Routine hearing exam (up to 1 every year): $20 copay. Exam to diagnose and treat hearing and balance issues- Fully covered Hearing aid fitting/evaluation (up to 1 every year): $20 copay Hearing aid: You pay nothing Our plan pays up to $500 every three years for hearing aids. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

20% of cost

Wigs are covered only for medically induced hair loss. Hearing aids, limited to one (1) single purchase once every three (3) years up to $500 , with replacement of accessories, repairs and batteries. Cochlear Implants One(1) per ear per time covered.

Prosthetic Devices: External: One (1) prosthetic device per limb, per lifetime and the cost and repair and replacement of the prosthetic devices and its parts.

Internal: included as part of inpatient hospitals services cost sharing.





Equipment and supplies can only be obtained from a contracted vendor. Non Participating Provider Services Are Not Covered

Wigs are covered only for medically



aids services L0112-L9900 Medicare Advantage



induced hair loss.

HEARING AIDS COVERED BY FFS MEDICAID

Prosthetic Devices: External: One (1) prosthetic device per



Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

0% OR 20% of cost

limb, per lifetime and the cost and repair and replacement of the prosthetic devices and its parts.




Equipment and supplies can only be obtained from a contracted vendor. Non Participating Provider Services Are Not Covered EXCLUSION:




aids services L0112-L9900 FIDA


Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. Personal emergency response services (PERS)


HEARING AIDS COVERED BY FFS MEDICAID

Prosthetic Devices: External: One (1) prosthetic device per limb, per lifetime and the cost and repair and replacement of the prosthetic

- Disposable medical supplies and enteral formula are covered by Medicaid Fee For Service with a provider's order. -Hearing Aids Batteries are covered as part of the prescription benefit (i.e. Medicaid Fee-For-Service)

Items listed in NY State Medicaid Program Description & Coverage Guidelines, Sections 4.1 and 4.2 (www.emedny.org) are not covered by MetroPlus, but covered by Medicaid Fee For Service.


Environmental Modifications/Assistive technology - physical adaptations to the private residence of the Participant or the Participant’s family. The adaptations must be necessary to ensure the health, welfare, and safety of the Participant or enable the Participant to function with greater independence in the home. Covered adaptations include ▪ Installation of ramps and grab bars ▪ Widening of doorways ▪ Modifications of bathrooms ▪ Installation of specialized electric and plumbing systems

Covered in full

devices and its parts.


Equipment and supplies can only be


obtained from a contracted vendor. Non Participating Provider Services Are Not Covered

Wigs are covered only for medically EXCLUSION: - Standard household items (e.g. air conditioners)


induced hair loss.

HEARING AIDS COVERED BY FFS

- Disposable medical supplies and enteral formula are covered by Medicaid Fee For Service with a provider's order.







MEDICAID

Prosthetic Devices: External: One (1) prosthetic device per


Items listed in NY State Medicaid Program Description &


evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

Covered in full

limb, per lifetime and the cost and repair and replacement of the prosthetic devices and its parts.

Enteral formula and nutritional supplements are limited to individuals who cannot obtain nutrition through any other means to the following conditions: tube fed; metabolic disorders

Coverage Guidelines, Sections 4.1 and 4.2 (www.emedny.org) are not covered by MetroPlus, but covered by Medicaid Fee For Service.









aids services L0112-L9900 BronzePlus HSA Medical Supplies Diabetic supplies, Ostomy supplies

Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.


Breast Pumps - covered in full












aids services L0112-L9900 SilverPrime





Diabetic Equipment, Supplies and Insulin (30-day supply) - $35 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder - $35 Copayment after Deductible Breast Pumps -covered in full

lifetime









aids services L0112-L9900 GoldPrime

Medical Supplies Diabetic supplies, Ostomy supplies Hearing Aid Services including selecting, fitting and dispensing of hearing aids, hearing aid checks following dispensing of hearing aids, conformity evaluations and hearing aid repairs .. Prosthetics are covered when medically necessary and include those appliances or devices which replace or perform the function of any missing part of the body. Please note: Artificial eyes &. Pacemaker Included




Orthotics are covered when medically necessary and include those appliances or devices which are used for the purpose of supporting a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body. 20% Coinsurance after deductible

Breast Pumps - covered in full Diabetic Equipment, Supplies and Insulin (30-day supply) $25 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder $25 Copayment after Deductible


DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Medicaid

Routine Dental Care: - Dental examinations, visits and consultations covered once within six (6) month consecutive period (when primary teeth erupt) - X-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month intervals or panoramic x-rays at 36 month intervals, if necessary, and other x-rays as required (once primary teeth erupt) - All necessary procedures for simple extractions and other routine dental surgery, including in-office conscious sedation - Amalgam or composite restorations and stainless steel crowns - Endodontics includes all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required. - Other restorative materials appropriate for children

Cosmetic dentistry, implants and orthodontia are not covered.

Authorization is required by MetroPlus Utilization

Management for anesthesia for inpatient or ambulatory oral

surgery.

Authorization is required by MetroPlus Utilization Management for anesthesia

for inpatient or ambulatory oral surgery.

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Essential Plan 1

Non-Aliessa

Routine Dental Care: - Dental examinations, visits and consultations covered once within six (6) month consecutive period (when primary teeth erupt) - X-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month intervals or panoramic x-rays at 36 month intervals, if necessary, and other x-rays as required (once primary teeth erupt) - All necessary procedures for simple extractions and other routine dental surgery, including in-office conscious sedation - Amalgam or composite restorations and stainless steel crowns - Endodontics includes all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required.

Preventive Dental Care, Routine Dental Care, & Major Dental: $15 Copayment

Inpatient dental surgery and ambulatory surgical procedures requiring anesthesia are covered in-network only. $150 Copayment for Inpatient Services. $50 Copayment for Ambulatory Surgery However, the professional services of the dentist are covered by HealthPlex. For Essential Plan Members Professional Services require $50 copayment




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Essential Plan 2

Non-Aliessa

Routine Dental Care: - Dental examinations, visits and consultations covered once within six (6) month consecutive period (when primary teeth erupt) - X-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month intervals or panoramic x-rays at 36 month intervals, if necessary, and other x-rays as required (once primary teeth erupt) - All necessary procedures for simple extractions and other routine dental surgery, including in-office conscious sedation - Amalgam or composite restorations and stainless steel crowns - Endodontics includes all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required. - Other restorative materials appropriate for children $0 No cost sharing by member

Inpatient dental surgery and ambulatory surgical procedures requiring anesthesia are covered in-network only. However, the professional services of the dentist are covered by HealthPlex. $0 No cost sharing by member




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Essential Plan 3/4

Aliessa

Routine Dental Care: - Dental examinations, visits and consultations covered once within six (6) month consecutive period (when primary teeth erupt) - X-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month intervals or panoramic x-rays at 36 month intervals, if necessary, and other x-rays as required (once primary teeth erupt) - All necessary procedures for simple extractions and other routine dental surgery, including in-office conscious sedation - Amalgam or composite restorations and stainless steel crowns - Endodontics includes all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required. Covered in full

Inpatient dental surgery and ambulatory surgical procedures requiring anesthesia are covered in-network only. However, the professional services of the dentist are covered by HealthPlex. Covered in full




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Child Health Plus

Routine Dental Care: - Dental examinations, visits and consultations covered once within six (6) month consecutive period (when primary teeth erupt) - X-ray, full mouth x-rays at 36 month intervals, if necessary, bitewing x-rays at 6-12 month intervals or panoramic x-rays at 36 month intervals, if necessary, and other x-rays as required (once primary teeth erupt) - All necessary procedures for simple extractions and other routine dental surgery, including in-office conscious sedation - Amalgam or composite restorations and stainless steel crowns - Endodontics includes all necessary procedures for treatment of diseased pulp chamber and pulp canals, where hospitalization is not required. - Other restorative materials appropriate for children

Preventive dental care includes procedures which help prevent oral disease from occurring, including but not limited to: - Topical fluoride application at six (6) month intervals where local water supply is not fluoridated

Inpatient dental surgery and ambulatory surgical procedures requiring anesthesia are covered in-network only. Fixed bridges are not covered unless: 1. Required for replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with an otherwise full complement of natural functional and/or restored teeth 2. Required for cleft palate treatment or stabilization




surgery.



- Sealants on unrestored permanent molar teeth - Space Maintenance: unilateral or bilateral space maintainers will be covered for placement in a restored deciduous and/or mixed detention to maintain space for normally developing permanent teeth.

Prosthodontics includes removable complete or partial dentures including six (6) months follow-up care. Additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate. Covered in full

3. Required, as demonstrated by medical documentation, due to the presence of any neurologic or physiologic condition that would preclude the placement of a removable prosthesis.

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex MetroPlus Enhanced

(HARP)

Routine Dental Care including, but not limited to the following: - Prophylaxis every six (6) months - Topical fluoride applications at six (6) month intervals - Examinations, visits and consultations every six (6) months - Full mouth/panoramic x-rays every three (3) years if necessary, bitewing x-rays at 6-12 month intervals, other x-rays as required - Simple extractions and other routine dental surgery, including pre-postoperative care and in-office conscious sedation - Amalgam or composite restorations and stainless steel or porcelain fused to metal crowns - Endodontic procedures for treatment of diseased pulp chamber and pulp canals - Complete or partial dentures including six (6) months of follow-up Covered in full

Inpatient dental surgery and ambulatory surgical procedures requiring anesthesia are covered in-network only. However, the professional services of the dentist are covered by HealthPlex.




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex HIV Special Needs

Routine Dental Care including, but not limited to the following: - Prophylaxis every six (6) months - Topical fluoride applications at six (6) month intervals - Examinations, visits and consultations every six (6) months - Full mouth/panoramic x-rays every three (3) years if necessary, bitewing x-rays at 6-12 month intervals, other x-rays as required - Simple extractions and other routine dental surgery, including pre-postoperative care and in-office conscious sedation - Amalgam or composite restorations and stainless steel or porcelain fused to metal crowns - Endodontic procedures for treatment of diseased pulp chamber and pulp canals - Complete or partial dentures including six (6) months of follow-up Covered in full

Inpatient dental surgery and ambulatory surgical procedures requiring anesthesia are covered in-network only. However, the professional services of the dentist are covered by HealthPlex.




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX N/A MetroPlus Gold NOT COVERED BENEFIT

Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-dental physiological condition that has resulted in severe functional impairment. - Treatment for tumors and cysts requiring pathological examination of




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX N/A MetroPlus GoldCare I NOT COVERED BENEFIT

Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-dental physiological condition that has resulted in severe functional impairment.




surgery.



- Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.

DENTAL SERVICES PROVIDED BY HEALTHPLEX N/A MetroPlus GoldCare II NOT COVERED BENEFIT





surgery.




DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex MedPlus

Catastrophic

Pediatric Preventive Dental Care 0% Coinsurance after deductible Pediatric Routine Dental Care 0% Coinsurance after deductible Pediatric Major Dental Care (Endodontics, Periodontics, Prosthodontics) 0% Coinsurance after deductible Orthodontics 0% Coinsurance after deductible

NO ADULT DENTAL COVERAGE

Pediatric Limits: One (1) dental exam and cleaning per six (6) month period.


Non-Participating Provider Services Are Not Covered and member will be responsible for entire cost.



surgery.




DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex BronzePlus


NON-STANDARD PLANS ADULT DENTAL COVERAGE Preventive Dental Care 50% Coinsurance after deductible Routine Dental Care 50% Coinsurance after deductible Major Dental Care (Oral Surgery, Endodontics, Periodontics, Prosthodontics) 50% Coinsurance after deductible Orthodontics 50% Coinsurance after deductible


Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-dental physiological condition that has resulted in severe functional impairment. - Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex SilverPlus

Pediatric Preventive Dental Care $30 Copayment after deductible Pediatric Routine Dental Care $30 Copayment after deductible Pediatric Major Dental Care (Endodontics, Periodontics, Prosthodontics) $30 Copayment after deductible Orthodontics $30 Copayment after deductible

NON-STANDARD PLANS ADULT DENTAL COVERAGE Preventive Dental Care 30% Coinsurance after deductible


Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-dental physiological condition that has resulted in severe functional




surgery.



Routine Dental Care 30% Coinsurance after deductible Major Dental Care (Oral Surgery, Endodontics, Periodontics, Prosthodontics) 30% Coinsurance after deductible Orthodontics 30% Coinsurance after deductible

impairment. - Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex GoldPlus


NON-STANDARD PLANS ADULT DENTAL COVERAGE


Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-




Preventive Dental Care $25 Copayment after deductible Routine Dental Care $25 Copayment after deductible Major Dental Care (Oral Surgery, Endodontics, Periodontics, Prosthodontics) $25 Copayment after deductible Orthodontics $25 Copayment after deductible

dental physiological condition that has resulted in severe functional impairment. - Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.

surgery.

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex PlatinumPlus

Pediatric Preventive Dental Care $15 Copayment Pediatric Routine Dental Care $15 Copayment Pediatric Major Dental Care (Endodontics, Periodontics, Prosthodontics) $15 Copayment Orthodontics $15 Copayment

NON-STANDARD PLANS ADULT DENTAL COVERAGE Preventive Dental Care $15 Copayment


Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-dental physiological condition that has resulted in severe functional




surgery.



Routine Dental Care $15 Copayment Major Dental Care (Oral Surgery, Endodontics, Periodontics, Prosthodontics) $15 Copayment Orthodontics $15 Copayment

impairment. - Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Medicare Platinum Limited Dental Services (this does not include services in connection with care, treatment. Filling, removal or replacement of teeth)

$0 No cost to member

Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-dental physiological condition that has resulted in severe functional impairment. - Treatment for tumors and cysts




surgery.



requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex Medicare Advantage

Limited Dental Services (this does not include services in connection with care, treatment. Filling, removal or replacement of teeth) 0% OR 20% of costs MEMBERS CAN USE FFS MEDICAID FOR DENTAL SERVICES





surgery.




DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex FIDA

Dental Services include necessary preventive, prophylactic and other dental care, services, supplies, routine exams, prophylaxis. Oral surgery and dental prosthetics and orthotic appliances required to alleviate a serious health condition including one which affects employability. $0 No cost to member




surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex MetroPlus Managed


Dental Services include necessary preventive, prophylactic and other dental care, services, supplies, routine exams, prophylaxis. Oral surgery and dental prosthetics and orthotic appliances required to alleviate a serious health condition including one which affects employability. $0 No cost to member

Non-Participating Provider Services Are Not Covered and member will be responsible for entire cost. ?

DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex BronzePlus HSA


ADULT DENTAL COVERAGE Preventive Dental Care 50% coinsurance after Deductible Routine Dental Care 50% coinsurance after Deductible Major Dental Care (Oral Surgery, Endodontics, Periodontics and Prosthodontics) 50% coinsurance after Deductible Orthodontics 50% Coinsurance after deductible






surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex SilverPrime


NON-STANDARD PLANS ADULT DENTAL COVERAGE Preventive Dental Care $35 Copayment after deductible Routine Dental Care $35 Copayment after deductible Major Dental Care (Oral Surrey, Endodontics, Periodontics, Prosthodontics) $35 Copayment after deductible Orthodontics $35 Copayment after deductible






surgery.



DENTAL SERVICES PROVIDED BY HEALTHPLEX Healthplex GoldPrime


NON-STANDARD PLANS ADULT DENTAL COVERAGE


Treatment for accidental injury to sound natural teeth, the jaw bones or surrounding tissues within twelve (12) months of the accident as long as the member is covered at the time services are rendered. - Treatment or correction of non-




Preventive Dental Care $25 Copayment after deductible Routine Dental Care $25 Copayment after deductible Major Dental Care (Oral Surrey, Endodontics, Periodontics, Prosthodontics) $25 Copayment after deductible Orthodontics $25 Copayment after deductible

dental physiological condition that has resulted in severe functional impairment. - Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of mouth.

surgery.

VISION CARE SERVICES V2020-V2615,V2700-V2799 Medicaid

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Replacement of lost or damaged glasses Members with Diabetes may self-refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optometrist not more than once in any 12 month period.

Only approved eyeglass frames (i.e. Medicaid approved) will be covered. - Replacement glasses should duplicate the original prescription and frames. - Examinations which include refraction are limited to every two (2) years unless otherwise justified as medically necessary. - Only one (1) pair of eyeglasses every two (2) years unless medically indicated (e.g. such as a change in correction greater than ½ diopter or unless the glasses are lost, damaged or destroyed). - Contact lenses and tinted lenses may be covered when medically necessary to treat a pathology (e.g. cataract)

Upgraded eyeglasses (e.g. designer eyeglass frames) or additional features such as scratch coating or photo-gray lenses are not covered. The member may choose to purchase upgraded eyeglass frames or features by paying the entire cost as a private customer. - Progressive lenses.

Y ‐ Contact lenses only Y - Contact lenses only

VISION CARE SERVICES V2020-V2615,V2700-V2799 Essential Plan 1 Non-Aliessa

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Replacement of lost or damaged glasses. Members with Diabetes may self-refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optician Optometrist not more than once in any 12 month period. 10% coinsurance




VISION CARE SERVICES V2020-V2615, V2700-V2799 Essential Plan 2 Non-Aliessa

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Replacement of lost or damaged glasses. Members with Diabetes may self-refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optician Optometrist not more than once in any 12 month period. $0 No cost sharing by member




VISION CARE SERVICES V2020-V2615,V2700-V2799 Essential Plan 3/4 Aliessa

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Replacement of lost or damaged glasses. Members with Diabetes may self-refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optician Optometrist not more than once in any 12 month period. Covered in full




VISION CARE SERVICES V2020-V2615,V2700-V2799 Child Health Plus

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary.

Only approved eyeglass frames will be covered. - Replacement glasses should duplicate the original prescription and frames. - Only one (1) pair of eyeglasses every year unless the prescription changes and is required more frequently with appropriate documentation. If medically necessary, more than one (1) pair of glasses will be covered. - Contact lenses and tinted lenses may be covered when medically necessary to treat a pathology (e.g. cataract)



VISION CARE SERVICES V2020-V2615, V2700-V2799 MetroPlus Enhanced (HARP)

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Repair or replacement of parts in situations where the damage is the result of causes other than defective workmanship - Replacement of lost or damaged glasses. Members with Diabetes may self- refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optician Optometrist not more than once in any 12 month period. Covered in full




VISION CARE SERVICES V2020-V2615,V2700-V2799 HIV Special Needs

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Repair or replacement of parts in situations where the damage is the result of causes other than defective workmanship - Replacement of lost or damaged glasses. Members with Diabetes may self- refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optician Optometrist not more than once in any 12 month period. Covered in full




VISION CARE SERVICES V2020-V2615,V2700-V2799 MetroPlus Gold All emergency, routine and preventive eye exams by a physician are covered. Services related to prosthetic eyes are covered. Refractive services for glasses and contact lenses and eyewear are not covered. N/A N/A

VISION CARE SERVICES N/A MetroPlus GoldCare I NOT COVERED BENEFIT Refractive services for glasses and contact lenses and eyewear are not covered. N/A N/A

VISION CARE SERVICES N/A MetroPlus GoldCare II NOT COVERED BENEFIT Refractive services for glasses and contact lenses and eyewear are not covered. N/A N/A

VISION CARE SERVICES V2020-V2615, V2700-V2799 MedPlus Catastrophic

Pediatric Vision Care Exams 0% Coinsurance after deductible Lenses and Frames 0% Coinsurance after deductible Contact Lenses 0% Coinsurance after deductible

NO ADULT VISION COVERAGE

One exam per 12 month period One prescribed lenses and frame per 12 month period


VISION CARE SERVICES V2020-V2615 ,V2700-V2799 BronzePlus

Pediatric Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. 50% Coinsurance after deductible Standard Prescription Lenses and Frames 50% Coinsurance after deductible Contact Lenses 50% Coinsurance after deductible

NON-STANDARD PLANS ADULT VISION COVERAGE Examinations 50% Coinsurance after deductible Lenses and Frames 50% Coinsurance after deductible Contact Lenses 50% Coinsurance after deductible


We do not Cover prescribed lenses and frames for Members after the end of the month in which the Member turns 19 years of age.


VISION CARE SERVICES V2020-V2615, V2700-V2799 SilverPlus

Pediatric Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. $30 Copayment after deductible Standard Prescription Lenses and Frames 30% Coinsurance after deductible Contact Lenses 30%Coinsurance after deductible

NON-STANDARD PLANS ADULT VISION COVERAGE Examinations $30 Copayment after deductible Lenses and Frames 30% Coinsurance after deductible Contact Lenses 30% Coinsurance after deductible




VISION CARE SERVICES V2020-V2615, V2700-V2799 GoldPlus

Pediatric Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses $25 Copayment after deductible Lenses and Frames 20% Coinsurance after deductible Contact Lenses 20% Coinsurance after deductible





VISION CARE SERVICES V2020-V2615, V2700-V2799 PlatinumPlus

Pediatric Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses $15 Copayment Lenses and Frames 10% Coinsurance Contact Lenses 10% Coinsurance

NON-STANDARD PLANS ADULT VISION COVERAGE Examinations $15 Copayment Lenses and Frames 10% Coinsurance Contact Lenses 10% Coinsurance




VISION CARE SERVICES V2020-V2615, V2700-V2799 Medicare Platinum Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts. Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. At risk populations for glaucoma. Eyeglasses or contact lenses after cataract surgery. (1) annual exam no cost to member.


VISION CARE SERVICES V2020-V2615, V2700-V2799 Medicare Advantage

Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts. Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. At risk populations for glaucoma. Eyeglasses or contact lenses after cataract surgery. 0% OR 20% Cost Y ‐ Contact lenses only Y - Contact lenses only

MEMBERS CAN USE FFS MEDICAID FOR VISION SERVICES

VISION CARE SERVICES V2020-V2615, V2700-V2799 FIDA

All emergency, preventive and routine eye care are covered. Eye care includes the services of an optometrist, ophthalmologist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Replacement of lost or damaged glasses Members with Diabetes may self-refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optometrist not more than once in any 12 month period. Covered in full




VISION CARE SERVICES V2020-V2615,V2700-V2799 MetroPlus Managed Long Term Care (MLTC)

Eye care includes the services of an optometrist and ophthalmic dispensers. Eye care services include: - Examinations to detect visual problems and/or eye disease. - Eyeglasses. - Contact lenses, Bifocals and polycarbonate lenses, if medically necessary. - Artificial eyes (stock or custom made). - Low vision aids and services. - Replacement of lost or damaged glasses Members with Diabetes may self-refer to a participating provider for a Dilated Eye Exam by an Ophthalmologist or Optometrist not more than once in any 12 month period. Covered in full




VISION CARE SERVICES V2020-V2615 ,V2700-V2799 BronzePlus HSA

Pediatric & Adult Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. 50% Coinsurance after deductible Standard Prescription Lenses and Frames 50% Coinsurance after deductible Contact Lenses 50% Coinsurance after deductible




VISION CARE SERVICES V2020-V2615 ,V2700-V2799 SilverPrime

Pediatric Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses. $35 Copayment after deductible Standard Prescription Lenses and Frames 30% Coinsurance after deductible Contact Lenses 30%Coinsurance after deductible





VISION CARE SERVICES V2020-V2615 ,V2700-V2799 GoldPrime

Pediatric Vision Care Examinations for the purpose of determining the need for corrective lenses, and if needed, to provide a prescription for corrective lenses $25 Copayment after deductible Lenses and Frames 20% Coinsurance after deductible Contact Lenses 20% Coinsurance after deductible





RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

Medicaid

Advanced Imaging Services, Diagnostic and Therapeutic Radiology Services include medically necessary services provided by qualified practitioners in the provision of diagnostic radiology, diagnostic ultrasound, nuclear medicine, radiation oncology and magnetic resonance imaging (MRI). These services may only be performed upon the order of a qualified practitioner. Performed in a PCP Office; Performed as Outpatient Hospital Services; Performed in a Freestanding Radiology Facility or Specialist Office

Coverage includes but is not limited to: - Routine x-ray - Mammography - Diagnostic ultrasound - CT Scan - Bone density - HITECH Radiology Covered in full

PET Scans

Spinal MRI the 2nd or more studies perfomed within a 12

month period

Yes - ALL OUT-OF-NETWORK

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148,



Advanced Imaging PCP Office $25 Copayment Specialist Office or Freestanding Radiology Facility $25 Copayment Outpatient Hospital $25 Copayment Diagnostic Radiology

PET Scans



72149, 72156, 72157, 72158, 72159 PCP Office $15 Copayment Specialist Office or Freestanding Radiology Facility $25 Copayment Outpatient Hospital $25 Copayment Therapeutic Radiology Specialist Office or Freestanding Radiology Facility $15 Copayment Outpatient Hospital $15 Copayment

month period

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148,



Coverage includes but is not limited to: - Routine x-ray - Mammography

PET Scans



72149, 72156, 72157, 72158, 72159 - Diagnostic ultrasound - CT Scan - Bone density - HITECH Radiology Covered in full

month period

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148,




PET Scans




month period

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

Child Health Plus



PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148,




None

PET Scans




month period

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

HIV Special Needs



None

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

MetroPlus Gold



None

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159



Coverage includes but is not limited to: - Routine x-ray - Mammography - Diagnostic ultrasound - CT Scan - Bone density

None

PET Scans


month period


- HITECH Radiology PCP - Included in PCP visit Copayment Specialist - Included in Specialist visit copayment Freestanding Radiology Facility $40 Copayment Outpatient Hospital Services $100 Copayment in Hospital

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159



Coverage includes but is not limited to: - Routine x-ray - Mammography - Diagnostic ultrasound - CT Scan - Bone density - HITECH Radiology Specialist - Included in Specialist visit copayment Freestanding Radiology Facility $50 Copayment Outpatient Hospital Services $150 Copayment in Hospital

None

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159



Advanced Imaging Specialist Office, Freestanding Radiology Facility or Outpatient Hospital 0 % Coinsurance after deductible Diagnostic Radiology PCP or Specialist office 0% Coinsurance after deductible Freestanding Radiology Facility 0% Coinsurance after deductible

PET Scans


month period


Outpatient Hospital 0% Coinsurance after deductible Therapeutic Radiology Specialist Office or Freestanding Radiology Facility 0% Coinsurance after deductible Outpatient Hospital 0% Coinsurance after deductible

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

BronzePlus


Advanced Imaging Freestanding Radiology Facility 50 % Coinsurance after deductible Outpatient Hospital 50% Coinsurance after deductible Diagnostic Radiology PCP office 50% Coinsurance after deductible Freestanding Radiology Facility 50% Coinsurance after deductible Outpatient Hospital 50% Coinsurance after deductible Therapeutic Radiology Freestanding Radiology Facility 50% Coinsurance after deductible Outpatient Hospital 50% Coinsurance after deductible

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

SilverPlus


Advanced Imaging Specialist Office, Freestanding Radiology Facility or Outpatient Hospital $50 Copayment after deductible Diagnostic Radiology PCP office $30 Copayment after deductible Specialist Office or Freestanding Radiology Facility $50 Copayment after deductible

PET Scans


month period


Outpatient Hospital $50 Copayment after deductible Therapeutic Radiology Specialist Office or Freestanding Radiology Facility $30 Copayment after deductible Outpatient Hospital $30 Copayment after deductible

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

GoldPlus


Advanced Imaging Specialist Office, Freestanding Radiology Facility or Outpatient Hospital $50 Copayment after deductible Diagnostic Radiology PCP office $30 Copayment after deductible Freestanding Radiology Facility $50 Copayment after deductible

PET Scans


month period


Outpatient Hospital $50 Copayment after deductible Therapeutic Radiology Freestanding Radiology Facility $30 Copayment after deductible Outpatient Hospital $30 Copayment after deductible

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

PlatinumPlus


Advanced Imaging Specialist Office, Freestanding Radiology Facility or Outpatient Hospital $35 Copayment Diagnostic Radiology PCP office $15 Copayment Specialist Office or Freestanding Radiology Facility $35 Copayment

PET Scans


month period


Outpatient Hospital $35 Copayment Therapeutic Radiology Specialist Office or Freestanding Radiology Facility $15 Copayment Outpatient Hospital $15 Copayment

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

Medicare Platinum

Advanced Imaging Services, Diagnostic and Therapeutic Radiology Services include medically necessary services provided by qualified practitioners in the provision of diagnostic radiology, diagnostic ultrasound, nuclear medicine, radiation oncology and magnetic resonance imaging (MRI). These services may only be performed upon the order of a qualified practitioner. Performed in a PCP Office; Performed as Outpatient Hospital Services; Performed in a Freestanding Radiology Facility or Specialist Office Coverage includes but is not limited to: - Routine x-ray - Mammography - Diagnostic ultrasound - CT Scan - Bone density - HITECH Radiology

20% of Cost

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

Medicare Advantage


Coverage includes but is not limited to: - Routine x-ray - Mammography - Diagnostic ultrasound - CT Scan - Bone density - HITECH Radiology 0% OR 20% of Cost

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

FIDA



PET Scans


month period


RADIOLOGY SERVICES N/A MetroPlus Managed Long Term Care (MLTC)

Advanced Imaging Services, Diagnostic and Therapeutic Radiology Services include medically necessary services provided by qualified practitioners in the provision of diagnostic radiology, diagnostic ultrasound, nuclear medicine, radiation oncology and magnetic resonance imaging (MRI). These services may only be performed upon the order of a qualified practitioner. Performed in a PCP Office; Performed as Outpatient Hospital Services; Performed in a Freestanding Radiology Facility or Specialist Office Coverage includes but is not limited to: - Routine x-ray - Mammography - Diagnostic ultrasound - CT Scan - Bone density - HITECH Radiology NOT COVERED BENEFIT

N/A N/A

RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

BronzePlus HSA


Advanced Imaging Freestanding Radiology Facility 50 % Coinsurance after deductible Outpatient Hospital 50% Coinsurance after deductible Diagnostic Radiology PCP office 50% Coinsurance after deductible Freestanding Radiology Facility 50% Coinsurance after deductible Outpatient Hospital 50% Coinsurance after deductible Therapeutic Radiology Freestanding Radiology Facility 50% Coinsurance after deductible Outpatient Hospital 50% Coinsurance after deductible

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

SilverPrime


Advanced Imaging Specialist Office or Freestanding Radiology Facility $55 Copayment after deductible Outpatient Hospital $55 Copayment after deductible Diagnostic Radiology PCP office $35 Copayment after deductible Specialist Office or Freestanding Radiology Facility $55 Copayment after deductible Outpatient Hospital $55 Copayment after deductible Therapeutic Radiology Specialist Office or Freestanding Radiology Facility $35 Copayment after deductible Outpatient Hospital $35 Copayment after deductible

PET Scans


month period


RADIOLOGY SERVICES

PET Scan Codes 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815,

78816

Spinal MRI Codes 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159

GoldPrime


Advanced Imaging Specialist Office, Freestanding Radiology Facility or Outpatient Hospital $40 Copayment after deductible Diagnostic Radiology PCP office $25 Copayment after deductible Specialist Office, Freestanding Radiology Facility or Outpatient Hospital $40 Copayment after deductible Therapeutic Radiology Specialist Office, Freestanding Radiology Facility or Outpatient Hospital $25 Copayment after deductible

PET Scans


month period


DIABETES SELF-MANAGEMENT G0108-G0109

G0108-G0109

G0108-G0109

G0108-G0109

G0108-G0109

G0108-G0109

Medicaid

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Covered in full

Non-Participating Providers Are Not Covered.

Diabetes supplies: lancets, glucometers, alcohol wipes are covered under pharmacy benefit. Diabetics with severe neuropathy or foot disease may also qualify for shoes which are covered under DME benefit.

NO Y‐OUT OF NETWORK

DIABETES SELF-MANAGEMENT


Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $15 Copayment












Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education Covered in full




DIABETES SELF-MANAGEMENT Child Health Plus

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education Covered in full










G0108-G0109DIABETES SELF-MANAGEMENT






G0108-G0109

G0108-G0109

G0108-G0109

G0108-G0109

G0108-G0109

HIV Special Needs





MetroPlus Gold






Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $20 Copayment per month Diabetic Equipment, Supplies and Insulin (30-day supply) - $20 Copayment per month



Y-DME Y‐OUT OF NETWORK


Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $30 Copayment per month Diabetic Equipment, Supplies and Insulin (30-day supply) - $30 Copayment per month



Y-DME Y‐OUT OF NETWORK


Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $0% Coinsurance after deductible




BronzePlus





G0108-G0109DIABETES SELF-MANAGEMENT





G0108-G0109

G0108-G0109

G0108-G0109

G0108-G0109

SilverPlus

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $30 Copayment after deductible Diabetic Equipment, Supplies and (30-day supply) $30 Copayment after Deductible




GoldPlus

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $25 Copayment after deductible




PlatinumPlus



Diabetes supplies: lancets, glucometers, alcohol wipes are covered under pharmacy benefit. Diabetics with severe neuropathy to foot disease may also qualify for shoes which are covered under DME benefit.


Medicare Platinum

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education Covered in full Diabetes monitoring supplies: 20% of the cost


Diabetes supplies: lancets, glucometers, alcohol wipes are covered under pharmacy benefit. Diabetics with severe neuropathy to foot disease may also qualify for shoes which are covered under DME benefit. Therapeutic shoes or inserts: 20% of the cost


Medicare Advantage

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education is 0% or 20% of the cost Diabetes monitoring supplies: 0% or 20% of the cost


Diabetes supplies: lancets, glucometers, alcohol wipes are covered under pharmacy benefit. Diabetics with severe neuropathy to foot disease may also qualify for shoes which are covered under DME benefit. Therapeutic shoes or inserts: 0% or 20% of the cost


DIABETES SELF-MANAGEMENT G0108-G0109 FIDA

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education is Covered in full




DIABETES SELF-MANAGEMENT N/A MetroPlus Managed


Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education is NOT COVERED BENEFIT



N/A N/A

DIABETES SELF-MANAGEMENT G0108-G0109

G0108-G0109

G0108-G0109

98960-98962

BronzePlus HSA





DIABETES SELF-MANAGEMENT SilverPrime

Diabetes Self-Management is designed to educate persons with diabetes as to the proper self-management and treatment of their diabetic condition, including information on proper diets. A new diagnosis; or a significant change in symptoms or condition which necessitates a change in Your self-management education; or when a refresher course is necessary. It must be provided in accordance with the following: By a Physician, other health care Provider authorized to prescribe under Title 8 of the New York Education Law. Diabetic supplies are provided by the pharmacy benefit. Diabetic Education $35 Copayment after deductible Diabetic Equipment, Supplies and Insulin (30-day supply) - $35 Copayment after Deductible




DIABETES SELF-MANAGEMENT GoldPrime





TREATMENT ADHERENCE SERVICES Medicaid

Adult Day Health Care Programs (ADHCP) and AIDS Adult Day Health Care- ADHCP includes the following services: -Individual and group counseling/education provided in a structured program setting Nursing care (including triage/assessment of new symptoms) - Medication adherence support -Nutritional services (including breakfast and/or lunch) -Rehabilitative services -Substance abuse services -Mental health services - HIV risk reduction services - Admission criteria must include, at a minimum, the need for general medical care and nursing services Covered in full

YES Y-ALL OUT OF NETWORK

TREATMENT ADHERENCE SERVICES N/A Essential Plan 1

Non-Aliessa NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES N/A Essential Plan 2

Non-Aliessa NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES N/A Essential Plan 3/4

Aliessa NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES N/A Child Health Plus NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES

98960-98962 H0015-H0016, H0036-H0037,H0039-H0040, H0046-H0047


Coverage includes treatment education policies and programs to encourage adherence to prescribed treatment regimens for all HARP members, promotion of access to treatment adherence and supportive services: -Assertive Community Treatment (ACT) - Continuing Day Treatment - ICM/Supportive CM - Community Psychiatric Support and Treatment (CPST) Adult Day Health Care Programs (ADHCP) and AIDS Adult Day Health Care- ADHCP includes the following services: -Individual and group counseling/education provided in a structured program setting Nursing care (including triage/assessment of new symptoms) - Medication adherence support -Nutritional services (including breakfast and/or lunch) -Rehabilitative services


-Substance abuse services -Mental health services - HIV risk reduction services - Admission criteria must include, at a minimum, the need for general medical care and nursing services Covered in full

TREATMENT ADHERENCE SERVICES HIV Special Needs

Coverage includes treatment education policies and programs to encourage adherence to prescribed treatment regimens for all HIV SNP members, promotion of access to treatment adherence and supportive services integrated into the continuum of HIV care services and development of management and operation designs that promote coordination and unification of treatment adherence services. Treatment adherence services include development and regular reassessment of an individual treatment adherence plan for each member consistent with the guidelines as developed by the AIDS Institute. Adult Day Health Care Programs (ADHCP) and AIDS Adult Day Health Care - ADHCP includes the following services: -Individual and group counseling/education provided in a structured program setting Nursing care (including triage/assessment of new symptoms) - Medication adherence support -Nutritional services (including breakfast and/or lunch) -Rehabilitative services -Substance abuse services -Mental health services - HIV risk reduction services - Admission criteria must include, at a minimum, the need for general medical care and nursing services Covered in full


TREATMENT ADHERENCE SERVICES N/A MetroPlus Gold NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

98960-98962

98960-98962

MetroPlus GoldCare I NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES MetroPlus GoldCare II NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES MedPlus

Catastrophic NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES BronzePlus NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES SilverPlus NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES GoldPlus NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES PlatinumPlus NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES Medicare Platinum NOT COVERED BENEFIT N/A N/A TREATMENT ADHERENCE

SERVICES Medicare Advantage NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES FIDA

MetroPlus FIDA Plan will pay for Adult Day Health Care, which includes the following services: Medical ▪ Nursing ▪ Food and nutrition ▪ Social services ▪ Rehabilitation therapy ▪ Leisure time activities, which are a planned program of diverse meaningful activities ▪ Dental ▪ Pharmaceutical ▪ Other ancillary services Covered in full MetroPlus FIDA Plan will pay AIDS Adult Day Health Care Programs (ADHCP) for Participants with HIV which includes the following services: ▪ Individual and group counseling/education provided in a structured program setting ▪ Nursing care (including triage/assessment of new symptoms) ▪ Medication adherence support ▪ Nutritional services (including breakfast and/or lunch) ▪ Rehabilitative services ▪ Substance abuse services ▪ Mental health services ▪ HIV risk reduction services Covered in full Social Adult Day Care is a structured, comprehensive day program in a protective setting for less than a 24-hour period that provides functionally impaired individuals with core and optional services, including: -Socialization -Supervision and Monitoring -Personal Care -Nutrition -Optional Services such as transportation and caregiver assistance Health and wellness education programs on topics including, but not limited to: heart attack and stroke prevention, asthma, living with chronic conditions, back care, stress management, healthy eating and weight management, oral hygiene, and osteoporosis Wellness Counseling - A Registered Professional Nurse (RN) works with the Participant to reinforce or teach healthy habits such as the need for daily exercise, weight control, or avoidance of smoking. Medical Social Services includes the assessment of social and environmental factors related to the Participant’s illness and need for care. Covered in full


TREATMENT ADHERENCE SERVICES


MetroPlus Managed Long Term Care (MLTC) supports a Medical Model of Adult Day Health Care Programs (ADHCP) including those who may have a diagnosis of HIV. ADHCP includes the following services: -Individual and group counseling/education provided in a structured program setting Nursing care (including triage/assessment of new symptoms) - Medication adherence support -Nutritional services (including breakfast and/or lunch) -Rehabilitative services -Substance abuse services -Mental health services - HIV risk reduction services Covered in full Social Adult Day Care is a structured, comprehensive day program in a protective setting for less than a 24-hour period that provides functionally impaired individuals with core and optional services, including: -Socialization -Supervision and Monitoring -Personal Care -Nutrition -Optional Services such as transportation and caregiver assistance Covered in full


TREATMENT ADHERENCE SERVICES N/A BronzePlus HSA NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES N/A SilverPrime NOT COVERED BENEFIT N/A N/A

TREATMENT ADHERENCE SERVICES N/A GoldPrime NOT COVERED BENEFIT N/A N/A

AUTISM SPECTRUM DISORDERS (ASD)



F84.0, F84.3-9 90832-90838 92521-92524 92507-92508 96110-96111 97161-97168 0359T-0374T E1902 E2508,E2510-E2512,E2599,G0153, V5336,V5362,V5363 H0031-H0032,H2012, H2014,H2019 S9152 T1025-T1027



Medicaid

Autism Spectrum Disorder when such services are prescribed or ordered by a licensed Physician or a licensed psychologist and are determined by Us to be Medically Necessary for the screening, diagnosis, and treatment of autism spectrum disorder

We Cover the rental or purchase of assistive communication devices when ordered or prescribed by a licensed Physician or a licensed psychologist if You are unable to communicate through normal means (i.e., speech or writing) when the evaluation indicates that an assistive communication device is likely to provide You with improved communication. Examples of assistive communication devices include communication boards and speech-generating devices. Coverage is limited to dedicated devices. We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We Cover assessments, evaluations, and tests to determine whether someone has autism spectrum disorder.

Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program and/or technical support is not

ASD RELATED DME REQUIRE AUTHORIZATION SEE DME

SERVICE TYPE Y-ALL OUT OF NETWORK

ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER AND FOR EQUIPMENT PLEASE SEE DME separately reimbursable. We will determine whether the device Coverage of applied behavior analysis services is limited to 680 hours per Member per Calendar Year.




Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program and/or technical support is not separately reimbursable. We will



ABA Treatment for Autism Spectrum Disorder $15 copayment Assistive Communication Devices for Autism Spectrum Disorder $15 copayment

ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER AND FOR EQUIPMENT PLEASE SEE DME

determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)







ABA Treatment for Autism Spectrum Disorder $0 Assistive Communication Devices for Autism Spectrum Disorder $0


determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year.(Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)






N/A







ABA Treatment for Autism Spectrum Disorder $0 Assistive Communication Devices for Autism Spectrum Disorder $0



Child Health Plus


We Cover the rental or purchase of assistive communication devices when ordered or prescribed by a licensed Physician or a licensed psychologist if You are unable to communicate through normal means (i.e., speech or writing) when the evaluation indicates that an assistive communication device is likely to provide You with improved communication. Examples of assistive communication devices include communication boards and speech-generating devices. Coverage is limited to dedicated devices. We will only Cover devices that generally are not useful to a person in the absence of a

Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program



communication impairment. We Cover assessments, evaluations, and tests to determine whether someone has autism spectrum disorder.


and/or technical support is not separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 hours per Member per Calendar Year





NOT A COVERED BENEFIT

Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program and/or technical support is not separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Calendar Year.

N/A N/A







HIV Special Needs






ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER AND FOR EQUIPMENT PLEASE SEE DME separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Calendar Year.

MetroPlus Gold







$0 Copayment

determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year. (Plan Year: The 12-month period beginning on the effective date of the Contract or any anniversary date thereafter, during which the Contract is in effect.)







ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER Provider Services $20 copay; unlimited visits per calendar year DME 20% coinsurance







F84.0, F84.3-9 90832-90838 92521-92524 92507-92508 96110-96111 97161-97168 0359T-0374T E1902 E2508,E2510-E2512,E2599,G0153, V5336,V5362,V5363 H0031-H0032,H2012, H2014,H2019 S0265, S9152 T1025-T1027







ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER Provider Services $30 copay; unlimited visits per calendar year DME 20% coinsurance








ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER PLEASE SEE RATES ABOVE AND FOR EQUIPMENT PLEASE SEE DME

0% Coinsurance after Deductible


BronzePlus








separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year.(Plan Year: A calendar year ending on December 31 of each year.)





F84.0, F84.3-9 90832-90838 92521-92524 92507-92508 96110-96111 97161-97168 0359T-0374T E1902 E2508,E2510-E2512,E2599,G0153, V5336,V5362,V5363 H0031-H0032,H2012, H2014,H2019 T1025-T1027

S9152


S9152

SilverPlus







ABA Treatment for Autism Spectrum Disorder - $30 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder - $30 Copayment after Deductible


GoldPlus







$25 Copayment after Deductible

Assistive Communication Devices for Autism Spectrum Disorder $25 Copayment after Deductible

separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)

PlatinumPlus



Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating




$15 Copayment

Assistive Communication Devices for Autism Spectrum Disorder $15 Copayment after Deductible

device. Installation of the program and/or technical support is not separately reimbursable. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)







S9152

S9152


S9152


S9152

Medicare Platinum



ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER PLEASE SEE RATES ABOVE AND FOR EQUIPMENT PLEASE SEE DME NOT COVERED BENEFIT

Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program and/or technical support is not separately reimbursable. We will determine whether the device should be purchased or rented.

N/A Y-ALL OUT OF NETWORK

Medicare Advantage



ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER PLEASE SEE RATES ABOVE AND FOR EQUIPMENT PLEASE SEE DME COVERED FEE FOR SERVICE MEDICAID

Coverage is limited to dedicated devices; We will only Cover devices that generally are not useful to a person in the absence of a communication impairment. We will not Cover items, such as, but not limited to, laptops, desktop, or tablet computers. We Cover software and/or applications that enable a laptop, desktop, or tablet computer to function as a speech-generating device. Installation of the program and/or technical support is not separately reimbursable. We will determine whether the device should be purchased or rented.



FIDA






ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER PLEASE SEE RATES ABOVE AND FOR EQUIPMENT PLEASE SEE DME COVERED FEE FOR SERVICE MEDICAID

separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Calendar Year





N/A N/A

ASSESSMENTS ARE PERFORMED BY OUTPATIENT MENTAL HEALTH PROVIDER PLEASE SEE RATES ABOVE AND FOR EQUIPMENT PLEASE SEE DME NOT COVERED BENEFIT

separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Calendar Year







BronzePlus HSA









SilverPrime







ABA Treatment for Autism Spectrum Disorder - $35 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder - $35 Copayment after Deductible


GoldPrime







ABA Treatment for Autism Spectrum Disorder $25 Copayment after Deductible Assistive Communication Devices for Autism Spectrum Disorder $25 Copayment after Deductible

separately reimbursable. We will determine whether the device should be purchased or rented. Coverage of applied behavior analysis services is limited to 680 Hours Per Plan Year. (Plan Year: A calendar year ending on December 31 of each year.)

WELLNESS BENEFITS N/A Medicaid

We will partially reimburse the Subscriber and the Subscriber’s covered Spouse for certain exercise facility fees or membership fees but only if such fees are paid to exercise facilities which maintain equipment and programs that promote cardiovascular wellness. Reimbursement is limited to actual workout visits. In order to be eligible for reimbursement, You must: (1) Be an active member of the exercise facility, and (2) Complete 50 visits in a six (6)-month period. In order to obtain reimbursement, at the end of the six (6)-month period, You must submit: (1) A completed reimbursement form; Documentation of the visits from the facility. Each time You visit the exercise facility, a facility representative must sign and date the documentation of the visits. (2) A copy of Your current facility bill which shows the fee paid for Your membership. (3) Reimbursement

Once We receive the completed reimbursement form and the bill, You will be reimbursed the lesser of $200 for the Subscriber and $100 for the Subscriber’s covered Spouse or the actual cost of the membership per six (6)-month period. Reimbursement must be requested within 120 days of the end of the six (6)-month period.

Memberships in tennis clubs, country clubs, weight loss clinics, spas or any other similar facilities will not be reimbursed. Lifetime memberships are not eligible for reimbursement.

N/A N/A

will not be provided if the member is in a grace period or has an outstanding premium payment. NOT A COVERED BENEFIT

Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner.

WELLNESS BENEFITS S9970, S9449, S9452, S9454, S9470,G0270-G0271,97803-97804


We will partially reimburse the Subscriber and the Subscriber’s covered Spouse for certain exercise facility fees or membership fees but only if such fees are paid to exercise facilities which maintain equipment and programs that promote cardiovascular wellness. Reimbursement is limited to actual workout visits. In order to be eligible for reimbursement, You must: (1) Be an active member of the exercise facility, and (2) Complete 50 visits in a six (6)-month period. In order to obtain reimbursement, at the end of the six (6)-month period, You must submit: (1) A completed reimbursement form; Documentation of the visits from the facility. Each time You visit the exercise facility, a facility representative must sign and date the documentation of the visits. (2) A copy of Your current facility bill which shows the fee paid for Your membership. (3) Reimbursement will not be provided if the member is in a grace period or has an outstanding premium payment.

Once We receive the completed reimbursement form and the bill, You will be reimbursed the lesser of $200 for the Subscriber or the actual cost of the membership per six (6)-month period. Reimbursement must be requested within 120 days of the end of the six (6)-month period. Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner.


N/A SEE MEMBER HANDBOOK

Once We receive the completed




reimbursement form and the bill, You will be reimbursed the lesser of $200 for the Subscriber or the actual cost of the membership per six (6)-month period. Reimbursement must be requested within 120 days of the end of the six (6)-month period. Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner.


N/A SEE MEMBER HANDBOOK N/A SEE MEMBER HANDBOOK

Once We receive the completed reimbursement form and the bill, You




will be reimbursed the lesser of $200 for the Subscriber and $100 for the Subscriber’s covered Spouse or the actual cost of the membership per six (6)-month period. Reimbursement must be requested within 120 days of the end of the six (6)-month period. Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner.



WELLNESS BENEFITS N/A Child Health Plus




N/A N/A

will not be provided if the member is in a grace period or has an outstanding premium payment. NOT COVERED BENEFIT


WELLNESS BENEFITS N/A MetroPlus Enhanced (HARP)




N/A N/A



WELLNESS BENEFITS N/A HIV Special Needs




N/A N/A



WELLNESS BENEFITS S9970 MetroPlus Gold




N/A N/A

will not be provided if the member is in a grace period or has an outstanding premium payment. Up to $250 per six (6) month period; up to an additional $250 per six (6) month period for Spouse


WELLNESS BENEFITS N/A MetroPlus GoldCare I




N/A N/A


Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner

WELLNESS BENEFITS N/A MetroPlus GoldCare II




N/A N/A


Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner

WELLNESS BENEFITS S9970 MedPlus Catastrophic


Once We receive the completed reimbursement form and the bill, You will be reimbursed the lesser of $200 for the Subscriber and $100 for the Subscriber’s covered Spouse or the actual cost of the membership per six (6)-month period. Reimbursement must be requested within 120 days of the end of the six (6)-month period. Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner.



WELLNESS BENEFITS S9970

S9970

S9970

S9970

BronzePlus





WELLNESS BENEFITS SilverPlus





WELLNESS BENEFITS GoldPlus





WELLNESS BENEFITS PlatinumPlus





will not be provided if the member is in a grace period or has an outstanding premium payment. Reimbursement will be issued only after You have completed each six (6)-month period even if 50 visits are completed sooner.

WELLNESS BENEFITS N/A Medicare Platinum




N/A N/A



WELLNESS BENEFITS N/A Medicare Advantage




N/A N/A



WELLNESS BENEFITS N/A FIDA




N/A N/A



WELLNESS BENEFITS N/A MetroPlus Managed Long Term Care (MLTC)




N/A N/A



WELLNESS BENEFITS S9970

S9970

S9970

BronzePlus HSA





WELLNESS BENEFITS SilverPrime





WELLNESS BENEFITS GoldPrime





TRANSGENDER SERVICES


Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Medicaid

Transgender Services: Gender dysphoria treatment. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment Surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received. For additional information, refer to: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Transgender%20Related%20Care%20and%20Services_0.pdf

Payment will not be made for the following services and procedures: (i) cryopreservation, storage, and thawing of reproductive tissue, and all related services and charges; (ii) reversal of genital and/or breast surgery; (iii) reversal of surgery to revise secondary sex characteristics; (iv) reversal of any procedure resulting in sterilization; and (v) cosmetic surgery, services, and procedures, including but not limited to: (a) abdominoplasty, blepharoplasty, neck tightening, or removal of redundant skin; (b) breast augmentation; (c) breast, brow, face, or forehead lifts; (d) calf, cheek, chin, nose, or pectoral implants; (e) collagen injections; (f) drugs to promote hair growth or loss; (g) electrolysis, unless required for vaginoplasty; (h) facial bone reconstruction, reduction, or sculpturing, including jaw shortening and rhinoplasty; (i) hair transplantation; (j) lip reduction; (k) liposuction; (l) thyroid chondroplasty; and (m) voice therapy, voice lessons, or voice modification surgery.

Y-TRANSGENDER Y-ALL OUT OF NETWORK







Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940






Transgender Services: Gender dysphoria treatmen t. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment Surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received. For additional information, refer to: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Transgender%20Related%20Care%20and%20Services_0.pdf





Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Child Health Plus

Transgender Services: Gender dysphoria treatment. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment NOT COVERED BENEFIT FOR SOME CHP MEMBERS DUE TO AGE REQUIREMENTS. CHP MEMBERS 16/19 YEARS OLD WILL BE REVIEWED ON CASE BY CASE BASIS. Surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received. For additional information, refer to: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Transgender%20Related%20Care%20and%20Services_0.pdf









Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

HIV Special Needs

Transgender Services: Gender dysphoria treatment . As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment Surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received. For additional information, refer to: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Transgender%20Related%20Care%20and%20Services_0.pdf



MetroPlus Gold

Transgender Services: Gender dysphoria treatment . As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Gender reassignment surgery may be covered for an individual who is 18 years of age or older, or 21 years of age or older if the surgery will result in sterilization, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist or psychologist with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. NOT COVERED BENEFIT


N/A N/A



Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940



Payment will not be made for the following services and procedures: (i) cryopreservation, storage, and thawing of reproductive tissue, and all related services and charges; (ii) reversal of genital and/or breast surgery; (iii) reversal of surgery to revise secondary sex characteristics; (iv) reversal of any procedure resulting in sterilization; and (v) cosmetic surgery, services, and procedures, including but not limited to: (a) abdominoplasty, blepharoplasty, neck tightening, or removal of redundant skin; (b) breast augmentation; (c) breast, brow, face, or forehead lifts; (d) calf, cheek, chin, nose, or pectoral implants; (e) collagen injections; (f) drugs to promote hair growth or loss; (g) electrolysis, unless required for vaginoplasty; (h) facial bone reconstruction, reduction, or sculpturing, including jaw shortening and rhinoplasty; (i) hair transplantation; (j) lip reduction; (k) liposuction;

N/A N/A

(l) thyroid chondroplasty; and (m) voice therapy, voice lessons, or voice modification surgery.



Payment will not be made for the following services and procedures: (i) cryopreservation, storage, and thawing of reproductive tissue, and all related services and charges; (ii) reversal of genital and/or breast surgery; (iii) reversal of surgery to revise secondary sex characteristics; (iv) reversal of any procedure resulting in sterilization; and (v) cosmetic surgery, services, and procedures, including but not limited to: (a) abdominoplasty, blepharoplasty, neck tightening, or removal of redundant skin; (b) breast augmentation; (c) breast, brow, face, or forehead lifts; (d) calf, cheek, chin, nose, or pectoral implants; (e) collagen injections; (f) drugs to promote hair growth or loss; (g) electrolysis, unless required for vaginoplasty; (h) facial bone reconstruction, reduction, or sculpturing, including jaw shortening and rhinoplasty; (i) hair transplantation; (j) lip reduction; (k) liposuction;

N/A N/A

(l) thyroid chondroplasty; and (m) voice therapy, voice lessons, or voice modification surgery.



Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940





BronzePlus






Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

SilverPlus

Transgender Services: Gender dysphoria treatment . As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery s hall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment Surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received. For additional information, refer to: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Transgender%20Related%20Care%20and%20Services_0.pdf



GoldPlus

Transgender Services : Gender dysphoria treatment . As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment Surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received. For additional information, refer to: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Transgender%20Related%20Care%20and%20Services_0.pdf





Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

PlatinumPlus




Medicare Platinum

Transgender Services: Gender dysphoria treatment. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment NOT COVERED BENEFIT


N/A N/A



Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Medicare Advantage

Transgender Services: Gender dysphoria treatmen t. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment COVERED FEE FOR SERVICE MEDICAID



FIDA

Transgender Services: Gender dysphoria treatment. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria. Payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause shall be made in specific cases if medical necessity is demonstrated and prior approval is received. Gender reassignment surgery shall be covered for an individual who is 18 years of age or older, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. payment for gender reassignment COVERED FEE FOR SERVICE MEDICAID





Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940


Transgender Services: Gender dysphoria treatment. As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Gender reassignment surgery may be covered for an individual who is 18 years of age or older, or 21 years of age or older if the surgery will result in sterilization, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist or psychologist with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment. NOT COVERED BENEFIT


N/A N/A

BronzePlus HSA






Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260,58262,58275,58290,58291, 58541-58544, 58550,58552-58554,58571-58573,58661,58720,58940

Dx:F64.0-F64.9,Z87.890 19303,19304,19324,19325,53415, 53420,53425.53430,54120,54125, 54520,54660,54690,55175,55180, 55866,55970,55980,56625,56805, 57106,57110,57291,57292,57295, 57296,57335,57426,58150,58180, 58260 58262 58275 58290 58291

SilverPrime

Transgender Services: Gender dysphoria treatment . As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Gender reassignment surgery may be covered for an individual who is 18 years of age or older, or 21 years of age or older if the surgery will result in sterilization, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist or psychologist with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual: (i) has a persistent and well-documented case of gender dysphoria; (ii) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones; (iii) has lived for 12 months in a gender role congruent with the individual’s gender identity, and has received mental health counseling, as deemed medically necessary, during that time; (iv) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and (v) has the capacity to make a fully informed decision and to consent to the treatment.



GoldPrime

Transgender Services: Gender dysphoria treatment . As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria. Hormone therapy, whether or not in preparation for gender reassignment surgery, may be covered for individuals 18 years of age or older. Gender reassignment surgery may be covered for an individual who is 18 years of age or older, or 21 years of age or older if the surgery will result in sterilization, and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist or psychologist with whom the individual has an established and ongoing relationship. The other letter may be from a licensed psychiatrist, psychologist, physician or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual.

Payment will not be made for the following services and procedures: (i) cryopreservation, storage, and thawing of reproductive tissue, and all related services and charges; (ii) reversal of genital and/or breast surgery; (iii) reversal of surgery to revise secondary sex characteristics; (iv) reversal of any procedure resulting in sterilization; and


in network authorization out-of-network …...service type cpt code lob benefit description...

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