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Your Covered Benefits

SilverSummit Healthplan covers many medical services for your healthcare needs. Some services must be prescribed by your doctor. Some services must also be approved by SilverSummit Healthplan before you get the service.

Services Description and Limits Prior Authorization Required
Allergy care   Yes, for some services
Ambulance – emergency Includes ground and emergency helicopterambulance. No
Behavioral Health services Age limitations may apply. Services includecrisis stabilization, inpatient psychiatrichospitalization, outpatient assessment andtreatment services, residential treatmentfacilities and rehabilitation services. Yes, for some services
Breast pumps   Yes
Chiropractic services Coverage is limited to members under 21years of age and referred from Early andPeriodic Screening Diagnosis & Treatment(EPSDT) screening by their PCP. Limited tofour visits per year. Yes, after four visits
Durable Medical Equipment (DME) Items that are not medically necessary,or are not ordered by a provider are notcovered. Yes, in some situations
Drugs: prescription/pharmacy   Yes, for some medications
Drugs: over-the-counter(OTC) Over-the-counter medications require adoctor’s prescription. No
Early and PeriodicScreening, Diagnosis andTreatment (EPSDT)/wellchildexam Services are for members age 20 andyounger. Well-Child exams, Sports andschool physicals annually. No
Eye care services and eyeglasses Under age 21, one exam every 12 months.Age 21 and older, one exam every 24months. All members, lenses and framesevery 12 months. No
Family planning Family planning services can be from anyMedicaid doctor or clinic. This includeswell-woman exams, screenings andpregnancy testing. No
Foot care Routine foot care is not covered. Foot careis covered for children under 21. Foot carevisits may be limited. Orthotics are coveredfor some conditions. Yes, in some situations
Hearing aids and services   Yes, for cochlear implants
High-risk prenatal andinfant services Care management provides special supportfor members at risk or with special healthneeds Notify plan
Home healthcare Care must be prescribed by your doctor.And, not able to be received at the hospitalor provider’s office. Other conditions apply. Yes
Hospice services Other than an inpatient facility. Yes
Immunizations for children Available to members age 21 and younger. No
Inpatient and outpatienthospital care Items that are not medically necessary arenot covered. Yes, including observationservices
Maternity care See your provider as soon as you knowyou are pregnant. Send us the Notice ofPregnancy (NOP) form at first visit. Prenatalthrough postpartum services are covered.  
Lab services and testing Paternity testing and infertility treatmenttests are not covered. Yes, in some situations
Nurse midwife services Covered with all in-network providers. Yes, for non-participatingprovider
Obstetric (OB) ultrasounds Two are allowed per pregnancy unlessordered by perinatologist Yes, if more than two
Office visits Covered with all in-network providers. Yes, for non-participatingprovider
Orthotics/prosthetics   Yes
Pain management Not applicable for post-operative painmanagement. Yes
Physician services One routine physical exam every 12 monthsperformed by your PCP. Health visits asneeded. Yes, for non-participatingprovider
Private duty nursing services Overnight nursing services and respite carehours are limited. Yes
Psychiatric hospital service   Yes
Psychiatric services   Yes, for some services
Psychology services   Yes, for some services
Radiology and x-rays Must be ordered by a provider. Yes, for high-tech radiologyincluding CT, MRI, MRA
Reconstructive surgery Surgery that is performed to make you lookbetter and is determined to be cosmetic isnot covered. Yes
Rehabilitation services   Yes
Skilled Nursing Facility care Items that are not medically necessary arenot covered. This includes private rooms orconvenience/comfort items. Yes
Sterilization services Sterilizations require informed consentforms 30 days prior to the date ofprocedures.Hysterectomies are covered on a limitedbasis. No
Therapy (occupational,physical, speech) services   Yes
Stop smoking/ tobaccocessation Certain medications, patches or gumto help you stop smoking are covered.Smoking cessation is covered throughTobacco-Free Nevada and National JewishHealth. Call 1-800-QUIT-NOW (784-8669)or 1-844-251-0004 for more information. No
Surgery   Yes, except in an emergency
Transplant services For Children under 21 years of age, anymedically necessary transplant that is notexperimental will be covered. For Adults,Corneal, Kidney, Liver and Bone Marrowtransplants will be covered if medicallynecessary. Yes
Urgent care   No

NOTE: There are some services that your doctor has to get authorization before giving you the care. If you want to know if a service needs authorization, you can call Member Services. The phone number is 1-844-366-2880, TTY: 1-844-804-6086, Relay 711. There is more information about this later in the handbook. See the “Prior Authorization for Services” section. Some other benefits you can use are telemedicine, telemonitoring and telehealth.