Benefit Explanation: Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits.
Specialist
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Dermatology virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.
Benefit Explanation: Certain off-label uses of cancer drugs will be covered in accordance with state law.
Non Preferred Brand Drugs
CoPay: $80.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.
Benefit Explanation: Certain off-label uses of cancer drugs will be covered in accordance with state law.
Generic Drugs
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.
Benefit Explanation: Certain off-label uses of cancer drugs will be covered in accordance with state law.
Specialty Drugs
CoPay: $350.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document.
Benefit Explanation: Certain off-label uses of cancer drugs will be covered in accordance with state law.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member's schedule of benefits
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Exclusions: Dependent children not covered for abortion.
Benefit Explanation: Abortion services available for first 16 weeks of pregnancy.
1-817-813-4562, TTY 711
