Medical Benefits

• Office visits with your Primary Care Provider (PCP), including regular checkups, routine labs and tests
• Referrals to specialists
• Eye and hearing exams
• Well-baby care
• Well-child care
• Immunizations (shots) for children and adults
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for members under age 21
• Help with quitting smoking or other tobacco use

• Pregnancy Care: Bright Start Program
• Childbirth education classes
• OB/GYN and hospital services
• One medically necessary postpartum home visit for newborn care and assessment following discharge, but no later than 60 days after delivery
• Care management services for high-risk pregnancies during pregnancy and for two months after delivery

• Inpatient care
• Outpatient care
• Labs, X-rays and other tests

• Must be medically necessary and arranged by AmeriHealth Caritas North Carolina
• Time-limited skilled nursing services
• Specialized therapies (including physical therapy, speech-language pathology and occupational therapy)
• Home health aide services (for help with activities such as bathing, dressing, preparing meals and housekeeping)
• Medical supplies

• Must be medically necessary and arranged by AmeriHealth Caritas North Carolina
• Help with common activities of daily living (including eating, dressing and bathing) for individuals with disabilities and ongoing health conditions

• Hospice care will be arranged by AmeriHealth Caritas North Carolina if medically necessary.
• Hospice helps patients and their families with the special needs that come during the final stages of illness and after death.
• Hospice provides medical, supportive and palliative care to terminally ill individuals and their families or caregivers.
• You can get these services in your home, in a hospital or in a nursing home.

• Services provided by ophthalmologists and optometrists (including routine eye exams and medically necessary lenses)
• Specialist referrals for eye diseases or defects

• Prescription drugs
• Some medicines sold without a prescription (also called "over-the-counter"), like allergy medicines
• Insulin and other diabetic supplies (like syringes, test strips, lancets and pen needles)
• Smoking cessation agents, including over-the-counter products
• Enteral formula (balanced nutrition designed for the tube-feeding of children)
• Emergency contraception
• Medical and surgical supplies

• The NC Medicaid Pharmacy Lock-In Program was established as mandated by legislation to restrict beneficiaries whose utilization of targeted medications with a significant potential for abuse and misuse (opioids and benzodiazepines) is documented as being excessive.
• Beneficiaries are "Locked-In" to one prescriber and one pharmacy for a two-year period in order to monitor and reduce unnecessary or inappropriate utilization of these targeted medications.
• This program is intended to prevent Medicaid beneficiaries from obtaining multiple prescriptions for and excessive quantities of these targeted medications through multiple visits to physicians and pharmacies.

• Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency.
• After you have received emergency care, you may need other care to help make sure you remain in stable condition.
• Depending on the need, you may be treated in the emergency department, in an inpatient hospital room or in another setting.
• Read more about our emergency and urgent care services.

• Respiratory care services
• Podiatry services
• Chiropractic services
• Cardiac care services
• Surgical services

• Must be ordered by a physician and authorized by AmeriHealth Caritas North Carolina
• Includes short-term, or rehabilitation, stays and long-term care for up to 90 days
• If you need nursing care for more than 90 days, you may need to enroll in a different health plan. Talk with your PCP or call Member Services at 1-855-375-8811 (TTY 1-866-209-6421) if you have questions.
• Covered nursing home services include medical supervision, 24-hour nursing care, assistance with daily living, physical therapy, occupational therapy and speech-language pathology.
• Nursing home services must come from a nursing home that is in AmeriHealth Caritas North Carolina's provider network. If you choose a nursing home outside of AmeriHealth Caritas North Carolina's network, and the services you need are available from a provider in the plan's network, you may have to transfer to another plan. Call Member Services at 1-855-375-8811 (TTY 1-866-209-6421) for help with questions about nursing home providers and plan networks.
• Talk with your PCP or call Member Services at 1-855-375-8811 (TTY 1-866-209-6421) for help finding a nursing home in our network.

You do not need a referral from your PCP for family planning services. Family planning services include:

• Birth control
• Birth control devices such as IUDs, implantable contraceptive devices and others that are available with a prescription
• Emergency contraception
• Sterilization services
• HIV and sexually transmitted infection (STI) testing, treatment and counseling
• Screenings for cancer and other related conditions

• Durable medical equipment, prosthetics or orthotics
• Hearing aid products and services
• Telemedicine
• Extra support to manage your health
• Home infusion therapy
• Rural Health Clinic (RHC) services
• Federally Qualified Health Center (FQHC) services
• Free clinic services