Health Summary Plan Description

Medical Benefits (including Mental Health and Substance Abuse Treatment)

As of January 1, 2016, ValueOptions is now Beacon Health Options. For more information, please see the Winter 2015 Take 2.

The Plan uses the BlueCard PPO network and The Industry Health Network (TIHN) for all network medical benefits except mental health and substance abuse. The Plan uses ValueOptions for network mental health and substance abuse benefits. Non-network services are also covered under these benefits.

Eligibility

Plan I

Plan I Earned, Self-Pay and Senior Performer participants and their enrolled dependents are eligible for the medical benefits, including treatment for mental health and substance abuse conditions. In accordance with the Mental Health Parity and Addiction Equity Act of 2008, Plan I medical coverage includes mental health and substance abuse benefits. This means that deductibles, coinsurance and out-of-pocket maximums for medical benefits now include mental health and substance abuse benefits.

Plan II

Plan II Earned and Self-Pay participants and their enrolled dependents are eligible for the medical benefits. Coverage for the treatment of mental health and substance abuse conditions is not included.

Deductible

Medical charges are subject to a calendar year deductible. The medical deductible is separate from the deductibles for any other benefits provided by the Plan, including the hospital, prescription drug and dental deductibles. The sole exception is the Plan I mental health and substance abuse medical deductible which is combined with the Plan I medical deductible. The amount of the medical deductible varies depending on whether or not you use network providers and the Plan for which you are eligible. Refer to the chart below.

The family deductible is satisfied when at least two or more family members have paid the amount of the family deductible in covered expenses, except that the Plan will not apply more than the individual deductible amount to any one family member. See the example under hospital "Deductible" on page 32.

The Plan applies expenses toward your deductible as it processes claims, rather than according to the date of service. Providers submit their claims in accordance with their own billing schedules and claims are frequently not received in the order of their date of service, particularly when multiple providers are used.

Medical Deductibles
  Network Non-Network
Plan I

TIHN – No deductible
 

BlueCard PPO / ValueOptions – $250 per person / $500 per family

$500 per person /
$1,000 per family
Plan II

TIHN – No deductible
 

BlueCard PPO– $500 per person / $1,000 per family

$750 per person /
$1,500 per family

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that applied toward your deductible under Plan I will apply toward your Plan II deductible. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.


Copays, Coinsurance and Out-of-Pocket Maximums

Once you have satisfied the annual deductible, the Plan will provide reimbursement of covered expenses as shown in the table below. You are responsible for the applicable copays and coinsurance. Copays are flat dollar amounts while the coinsurance is a percentage of the Plan's Allowance.

The out-of-pocket maximum is the maximum amount you will have to pay for covered expenses during the calendar year after your deductible is satisfied. For example, a participant who is single and who has satisfied her deductible is responsible for 10% of the first $10,000 of covered network medical expenses, or $1,000. This is called the coinsurance. When you have
paid your deductible and the maximum out-of-pocket amount, the Plan will pay 100% of covered expenses with the exception of network copays.

Plan I mental health and substance abuse out-of-pocket medical expenses are combined with Plan I out-of-pocket medical expenses.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that applied toward your out-of-pocket maximum under Plan I will apply toward your Plan II out-of-pocket maximum. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.

Medical Copays, Coinsurance and Out-of-Pocket Maximums
See Take 2 Winter 2013 See Take 2 Summer 2014
Plan I Network Non-Network
Copays $15 per office visit;

$15 for surgery performed in a doctor's office*;

$100 per inpatient surgery;

$100 per outpatient surgery**;

$100 maternity care – delivery
None
Plan Pays 90% of Contract Allowance
70% of Plan's Allowance
Coinsurance 10% of Contract Allowance
30% of Plan's Allowance
Out-of-Pocket Maximum $1,000 per person / $2,000 per family $2,500 per person / $5,000 per family
Plan II Network Non-Network
Copays

$25 per office visit;

$25 for surgery performed in a doctor's office*;

$100 per inpatient surgery;

$100 per outpatient surgery**;

$100 maternity care – delivery

None
Plan Pays 90% of Contract Allowance 70% of Plan's Allowance
Coinsurance 10% of Contract Allowance
30% of Plan's Allowance
Out-of-Pocket Maximum $1,000 per person / $2,000 per family $2,500 per person / $5,000 per family

* If surgery is performed during a scheduled office visit, you are only responsible for one copay for that visit.
** This applies to surgery performed in i) the outpatient department of a hospital, ii) a freestanding surgical center, or iii) a physician's surgical suite.


Medical Benefits (other than Mental Health and Substance Abuse )

The Health Plan covers a wide range of medical services including the following:

  • Ambulance – Professional ambulance service and regularly scheduled airlines or railroads for emergency transportation to or from the nearest legally constituted hospital which has the facilities to treat your medical problem. Services provided to relocate a patient for family or personal convenience are not covered.
  • Anesthetics and their administration. See page 46 for anesthesia limits for colonoscopy and upper gastrointestinal endoscopy.
  • Artificial limbs and eyes, crutches, splints, casts and braces, surgical dressings, and medical supplies when prescribed by a doctor, including:
    • Initial charge for appliances to replace or aid the function of physical organs or parts (does not include dental appliances).
    • Initial pair of orthopedic or corrective shoes following surgery.
    • Orthopedic or corrective shoes for children under 12, two pairs in a calendar year.
  • Birth control for women– Norplant, IUDs and Depo-Provera. Birth control received from a network provider is not subject to the deductible or coinsurance. (Birth control pills, diaphragms, vaginal rings and patches are covered under the Express Scripts prescription drug program.)
  • Blood and plasma, except Protein Rich Plasma.
  • Breast implant removal when medically necessary due to pain from contracture or rupture of an implant – The Plan will cover the cost to remove the implant but not the cost of a replacement implant or reconstruction. Benefits are payable for a maximum of one surgery per breast per lifetime. This limit does not apply to breast surgeries resulting from cancer treatment. Please see page 46 for surgery pre-authorization requirements.
  • Breast pumps – Rental or purchase from a network provider only. Total rental payments are limited to the Plan's Allowance for purchase. Breast pumps are not subject to the deductible or coinsurance and are limited to one pump per birth.
  • Cardiac and cerebrovascular rehabilitative therapy – Benefits are payable for a maximum of three months, if such therapy commences within six months of a clinical cardiac or CVA (cerebrovascular accident) episode.
  • Certified nurse practitioner acting within the scope of his or her license.
  • Cervical traction units, except those prescribed by a chiropractor or naturopath.
  • Chemotherapy.
  • Christian Science practitioner – The Plan does not pay for any medical treatment when you are receiving services from a Christian Science practitioner. The Plan does not pay for Christian Science homes or sanitariums.
  • Cosmetic surgery, only if necessary:
    • For the prompt repair of accidental injury; or
    • To repair birth defects (congenital anomalies) as certified by a doctor, on individuals under 19 years of age; or
    • For certain reconstructive surgery following a mastectomy, including reconstruction of the breast on which the mastectomy was performed, surgery on the other breast to
      produce a symmetrical appearance, and prostheses and physical complications of all stages of mastectomy, including lymphedemas (as required by the Women's Health and
      Cancer Rights Act of 1998).
  • Dentist's charges as a result of accidental injury to natural sound teeth when repair work is completed within six months of the accident. A natural sound tooth is one which has not been restored or has been restored with amalgam or composite filling. A natural sound tooth does not include a missing tooth. The Plan may consider the repair of a tooth which was previously crowned provided the accidental injury is due to external causes and resulted in either hospitalization or surgery to the injured tooth. If approved under the medical benefits, no coverage is available under the dental benefits.
  • Dentist's charges for the removal of cysts and tumors.
  • Dialysis treatment.
  • Drugs and medications that are injectable or infusible and administered by the doctor's office, including allergy shots. (Specialty medications are covered under the Express Scripts prescription drug program and must be obtained through the Accredo specialty pharmacy.)
  • Drugs and medications requiring a doctor's or a dentist's prescription and dispensed by a registered pharmacist for eligible participants who are not covered by the Express Scripts prescription drug program (see page 55). Benefits are payable at the non-network level subject to the medical deductible.
  • Drugs that do not require a prescription if you are under the care of a physician for a current illness. The doctor must state, in writing, to the Plan Office the necessity for the use of such medication for the treatment of your illness. The nonprescription drugs must be generally accepted treatment for a given condition or illness. Not included are non-drug items dispensed in the doctor's office, food and/or nutritional supplements and homeopathic remedies or vitamins taken orally, by injection or by infusion.
  • Durable medical equipment (DME) – Rental or purchase of items when prescribed by a medical doctor, provided by a qualified DME supplier, and determined to be medically necessary by the Plan. Total rental payments are limited to the Plan's Allowance for the purchase of the equipment. If equipment is to be used for an extended period of time purchase may be preferred. NOT ALL EQUIPMENT IS COVERED. CHECK WITH THE PLAN OFFICE. DME that does not require a medical doctor's prescription is not covered. Neither is DME that is prescribed by an acupuncturist or chiropractor, or DME purchased from a non-qualified supplier such as Amazon or eBay.
Note: In order for the Plan to consider charges for DME, the equipment must meet the criteria outlined in the Glossary under "Durable Medical Equipment" on pages 107 and 108.
  • Eyeglasses (initial pair only), or contact or scleral lenses when required following a covered eye surgery.
  • Food allergy testing, when performed as part of the normal work-up of an allergy patient. The tests must be medically necessary. The Plan does not cover allergy treatments such as food antigens.
  • Foot orthotics when prescribed by a doctor, subject to the following replacement guidelines:
    • Age 16 or younger – One pair every 12 months.
    • Age 17 or older – One pair every 24 months.
    The Plan does not cover additional pairs of orthotics purchased for different styles of shoes.
  • Hearing aids for:
    • Participants and dependents covered under Plan I; and
    • Individuals under age 19 who have congenital hearing defects and are covered under Plan II.
    This benefit is payable at either 90% or 70%, as applicable, up to a maximum payment of $1,500 per device. Devices are limited to one per ear per three-year period. Repairs and battery replacement are not covered. Cochlear implants are not subject to these limits.
  • Home health care (may include nursing, durable medical equipment, and other medical supplies such as IV medications) – Please see page 52 for limitations on nursing and page 40 for limitations on durable medical equipment.
  • Hospice – Outpatient hospice care provided by a Medicare-certified program, when an individual is terminally ill with a life expectancy of less than 12 months. Hospice benefits are not subject to the deductible. Inpatient hospice care may be covered under the hospital benefits.
  • Lab and diagnostic tests to diagnose an illness or injury. Only tests which are appropriate for the clinical diagnosis as determined by medical consultants for the Plan will be considered. All tests are subject to medical review. Lab tests that are part of a panel will not be paid as separate tests.
  • Lactation support and counseling – Services are not subject to the deductible, copay or coinsurance. Benefits for non-network lactation consultants require that the consultant be an International Board Certified Lactation Consultant and are subject to a lifetime maximum of three visits.
  • Mammogram.
  • Nutritional counseling by a Registered Dietitian (R.D.) for participants or dependents with chronic illnesses such as diabetes (including gestational diabetes), coronary artery disease,
    ulcerative colitis, Crohn's Disease, malabsorption syndrome, cystic fibrosis, HIV/AIDS and cancer. Nutritional counseling is not subject to the deductible or the network copay and is limited to one initial and two follow-up visits per person per lifetime.
  • Obstetrical care and delivery for participants or their spouses or same-sex domestic partners, when provided by a M.D., Certified Nurse Midwife or State-Licensed Midwife, including pre and post-natal care and delivery. Additional charges for diagnostic tests such as ultrasound or amniocentesis may be considered separately, if medically necessary. Prenatal care from a network provider is not subject to the deductible, copay or coinsurance. If you change obstetricians and/ or midwives during your pregnancy, the Plan will
    only consider charges up to the global maternity allowance.
  • Obstetrical prenatal care for dependent children when provided by a network provider (M.D., Certified Nurse Midwife or State-Licensed Midwife). This care is not subject to the deductible, copay or coinsurance. Complications of pregnancy are covered for both network and non-network providers, subject to the medical deductible, copay and coinsurance. Delivery and post-natal services are not covered, nor are prenatal charges from a non-network provider.
  • Oxygen and its administration.
  • Pap test.
  • Pediatrician's charges for attendance at birth by cesarean section.
  • Physician's services – Fees of a legally qualified licensed physician or surgeon for professional medical or surgical services in or out of the hospital or at an urgent care center.
  • Private duty outpatient nursing (R.N., L.V.N., L.P.N. or equivalent state license) other than a relative or resident in your home when approved in advance, see page 52.
  • Psychological testing when approved in advance. Psychological testing in connection with learning disabilities, academic accommodations, or mental health or substance abuse treatment is not covered.
  • Pulmonary rehabilitation.
  • Radiation therapy.
  • Radium and radioactive isotope therapy.
  • Rast testing – The Plan will consider the minimum number of tests that are medically required in order to make a diagnosis.
  • Sleep studies (Polysomnography) when approved in advance. The Plan Office will review the referring physician's clinical exam notes and a completed sleep study questionnaire, which includes the Epworth Sleepiness Scale. Home studies and separate sleep studies to determine C-PAP titration are not covered unless medically necessary. The Plan covers treatment of sleep apnea when documented by medical records. Sleep studies performed for primary snoring are not covered.
  • Temporomandibular joint syndrome (TMJ) treatment, only when osseous changes (bony abnormalities) exist and can be determined by x-ray or other appropriate imaging techniques or in situations in which soft tissue degeneration in the temporomandibular joint can be documented. Dental expenses in connection with orthodontia are not included.
  • Therapy benefits, subject to specific limitations. Refer to pages 47 and 48.
  • Therapy exam – One initial medical exam per type of therapy for the doctor or covered therapist who is providing covered therapy treatment. For physical therapy and physical medicine, the Plan will also consider an additional exam.
  • Urgent care centers.
  • Visiting nurse when approved in advance (limited to reasonable and customary both by amount and frequency of visits). Each visit counts as one hour toward the 672 hour maximum as described on page 52.
  • Wellness or preventive services, such as physical exams and certain diagnostic tests, subject to specific limitations. Refer to pages 48 through 51.
  • Wigs – Limited to one per lifetime following cancer treatment.
  • X-rays, CT scans or MRIs to diagnose an illness or injury. Only tests which are appropriate for the clinical diagnosis as determined by medical consultants for the Plan will be considered.

Mental Health and Substance Abuse Benefits (Plan I only)

Mental health and substance abuse benefits cover a vast number of conditions. Among them are anxiety, stress, eating disorders, depression, bi-polar disorders such as manic depression, psychosis, schizophrenia and substance abuse (alcohol and drugs). If you have a question about a particular mental health or substance abuse condition and whether it is covered please contact ValueOptions at (866) 277-5383 or visit www.valueoptions.com/sagph.

All mental health and substance abuse medical claims, whether network or non-network, are administered by ValueOptions. See page 85 for how to file a claim. Benefits include the following:

  • Professional fees for disorders listed in the Mental Disorders section of the current edition of the International Classification of Diseases publication. Not all diagnoses are covered. Please contact ValueOptions for additional information.
  • Psychiatrist or Psychopharmacologist for drug management.
  • Psychotherapy (for psychological testing see page 42).

Special Rules for Radiology, Anesthesiology and Pathology (RAP) Providers

If a network physician refers you to a non-network radiology, anesthesiology or pathology (RAP) provider, the Plan will pay the Network Level of Benefits for the RAP claims. Payment will be based on the Plan's Allowance and you will be responsible for charges over this amount. When the Plan Office receives a RAP claim it is not always clear that you were referred by
a network doctor. You must let the Plan Office know about the referral so that RAP benefits can be paid at the network level.

You will also receive the Network Level of Benefits (based on the Plan's Allowance) if you receive RAP services as an inpatient or outpatient at a network hospital or facility, regardless of whether or not you were referred by a network physician.

Note: For a colonoscopy or upper gastrointestinal endoscopy, the Plan will cover moderate sedation when performed by the surgeon or a member of his or her team. A separate anesthesiologist's charges will not be covered unless the Plan's medical consultants determine that it is medically necessary. You should check with your surgeon before the procedure to determine if he or she intends to use a separate anesthesiologist as this may increase your out-of-pocket expenses.

Surgical Benefits

Contact the Plan Office before undergoing any surgical procedure to determine if the procedure is covered under the Plan, if a pre-authorization is required and if there are any limitations.

Obtaining a Second Opinion

The Plan encourages you to obtain a second opinion when surgery is recommended. A second opinion assists you in determining whether surgery is required or whether some alternative treatment may also be appropriate. The Plan will pay 100% of the Allowed Amount for a second (or third) opinion for you or your dependent for a covered surgery. The deductible and copay/coinsurance amount will not apply to the second (or third) opinion.

Transplants

With the exception of corneal transplants, expenses incurred in connection with organ transplants will not be considered as a covered expense under the Plan unless a written pre-authorization approval is obtained. The Plan reserves the right to deny coverage for a transplant if it is not performed in a Blue Distinction Center or Center of Excellence. Anthem Blue Cross maintains the list of these authorized network facilities. To obtain pre-authorization for a transplant, please follow the instructions under "Pre-Authorization for Surgery" on page 46.

If your transplant surgery is approved by the Plan, donor expenses are considered for payment provided the donor does not have such coverage under his or her own medical insurance plan. Written documentation from the donor's insurance plan is required. However, if you are donating an organ to another person, the Plan does not consider your donor expense for coverage because it is not considered a medically necessary expense for you.

If you or your dependents are covered under more than one health plan, including AFTRA, Directors or Writers, we recommend that you obtain pre-authorization from all plans.

Bariatric Surgery

Bariatric surgery will be considered as a covered expense if you receive a written pre-authorization approval from the Plan and you have:

  • A Body Mass Index (BMI) of at least 40; or
  • A BMI of at least 35 with other weight-related health conditions such as diabetes or hypertension.

To obtain pre-authorization for a bariatric surgery, please follow the instructions under "Pre-Authorization for Surgery" on page 46.

Cosmetic Surgery and Other Cosmetic Procedures

The Plan does not cover cosmetic surgeries or procedures except under specific limited conditions. Eyelid, nasal, and breast surgeries have a mandatory pre-authorization requirement. The Plan will cover cosmetic surgery necessary for the prompt repair of accidental injury, or to repair birth defects of an individual under age 19, or for certain reconstructive surgery following
a mastectomy.

If your doctor advises you that surgery is required for functional reasons, it is strongly recommended that you obtain pre-authorization before the surgery is performed. That way you will know whether it is covered. The final amount payable will not be determined until the actual operative report is reviewed. In all cases, your doctor will be asked to furnish certain information to the Plan. If you are required to be examined by an independent medical examiner selected by the Plan, the cost of the examination will be paid by the Plan.

The following is a list of some of the cosmetic surgeries and procedures NOT covered by the Plan.

  • Abdominoplasty.
  • Alopecia senilis or male pattern baldness treatment.
  • Blepharoplasty (eyelid) – Elective surgery to the upper eyelids is generally not covered, however, under certain circumstances it may be reviewed by the Plan's medical consultants to determine if it meets the criteria for a covered expense. Please have your physician follow the Surgery Pre-Authorization procedures on page 46 and provide an ophthalmologist's report which includes an automated visual field test and preoperative frontal and lateral gaze photos.
  • Botox injections, except for the treatment of certain medical conditions as approved by the FDA.
  • Breast reduction – Elective breast reduction is generally not covered, however under certain circumstances it may be reviewed by the Plan's medical consultants to determine if it meets the criteria for a covered expense. Please have your physician follow the Surgery Pre-Authorization procedures on page 46 and include the patient's height, weight and the number of grams of tissue to be removed from each breast.
  • Chemical peel, except for severe acne when accepted treatment has failed.
  • Collagen injections, except when used for the restoration, repair and correction of abnormalities or defects caused by an accident or covered surgery.
  • Dermabrasion.
  • Dermatology procedures for skin conditions which do not require treatment, such as the removal of freckles, age spots, wrinkles, etc.
  • Genioplasty (chin implants).
  • Gynecomastia surgery for enlarged male mammary glands, except for documented hormone imbalance or presence of tumor in the breast or an endocrine producing tumor.
  • Hair transplants.
  • Laser hair removal.
  • Laser resurfacing.
  • Lipectomy.
  • Liposuction.
  • Otoplasty (ear).
  • Panniculectomy.
  • Repair of diastasis recti when done at the same time as abdominoplasty, panniculectomy or lipectomy.
  • Revision of scar tissue from previous cosmetic surgery. See page 39 for information on breast implant removal.
  • Rhinoplasty (nose).
  • Rhytidectomy (face lift).
  • Telangiectasia (spider veins) treatment.

Pre-Authorization for Surgery

Transplants, bariatric surgery and eyelid, nasal and certain breast surgeries have a mandatory pre-authorization requirement. Breast surgeries that are required by the Women's Health and Cancer Rights Act of 1998 do not require pre-authorization. See page 40 for information on these surgeries.

To obtain pre-authorization for surgery, the following steps must be taken.

  1. You must advise your physician of the Plan's pre-authorization requirement. Your doctor is required to contact the Plan and provide all of the necessary information directly to the Plan Office.

  2. Your surgeon must submit a letter stating the surgical procedures to be performed, the medical necessity for the surgery and the anticipated fee for the surgery. The doctor's request for pre-authorization must be sent to the Plan Office and must include the patient's history and physical report, together with diagnostic quality preoperative photographs for eyelid, nasal and breast surgeries. The Plan's medical consultants will review the information and the Plan will advise you in writing if the surgery is covered. The final amount payable will not be determined until the actual operative and pathology reports are reviewed. If your doctor performs different or additional procedures than those that were pre-authorized, and these procedures are not covered under the Plan, these charges will not be considered for payment.

Surgeon

The Plan provides coverage for the surgeon's fee for covered surgeries. A copy of the operative and pathology reports are required for most surgeries. Please have your surgeon include the reports when the surgeon's charges are submitted. Surgical benefits are payable whether surgery takes place in or out of the hospital.

Assistant Surgeon

The Plan will consider 20% of the amount that is considered for the surgeon if a M.D. assistant is necessary for the procedure. The Plan will consider 10% of the amount that is considered for the surgeon if a non-M.D. assistant such as a Registered Nurse First Assistant or Physician Assistant is necessary for the procedure.

Anesthesiologist

The Plan will consider an allowance that takes into account the type of surgery, time in attendance and area of the country in which the surgery is performed. Please see page 43 for special rules on when network benefits are paid for anesthesiology and other RAP services.

Note: For a colonoscopy or upper gastrointestinal endoscopy, the Plan will cover moderate sedation when provided by the surgeon or a member of his or her team. A separate anesthesiologist's charges will not be covered unless the Plan's medical consultants determine that it is medically necessary. You should check with your surgeon before the procedure to determine if he or she intends to use a separate anesthesiologist as this may increase your out-of-pocket costs.

Benefits for More Than One Surgery

If multiple surgical procedures are performed at the same time, whether through the same or separate incisions, the Plan's Allowance is limited as follows:

  • 100% of covered expenses will be allowed for the major procedure;
  • 50% of covered expenses for the second procedure; and
  • 25% of covered expenses for each remaining procedure.

Procedures that are considered global to or incidental to another covered procedure are not allowable.

Use of a Non-Network Surgical Suite, Ambulatory Surgical Center or Birthing Center

A surgical suite or an ambulatory surgical center is a site, either in a doctor's office or an independent facility, where outpatient surgery is performed. If the surgery takes place in a non-network surgical suite or ambulatory surgical center, the Plan will allow up to $1,000 for use of the facility's operating and recovery rooms and all central supplies when medically
necessary for the procedure performed. The Plan will also allow up to $1,000 for the use of a non-network birthing center. Coverage for network surgical suites and surgical centers and for network birthing centers is provided under the hospital benefits.

Therapy Benefits (excluding Mental Health and Substance Abuse)

Contact the Plan Office before undergoing any type of therapy to determine if the therapy and provider are covered and if there are any limitations. All therapy visits must be medically necessary for the diagnosis or treatment of an accidental injury, sickness, pregnancy or other medical condition. For a complete definition of medical necessity, please see pages 108 and 109.

Medically necessary therapy for mental health and substance abuse treatment is covered under Plan I but it is not subject to the non-network allowances or visit limits outlined in this section.

Covered Therapies and Providers

The Plan will consider charges for the following therapies subject to the limitations noted:

  • Acupuncture when performed by a licensed Certified Acupuncturist. No benefits will be paid for any diagnostic tests performed or ordered by a Certified Acupuncturist or for equipment or supplies prescribed by a Certified Acupuncturist even if the provider is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
  • Biofeedback only if biofeedback is recommended and/or prescribed by a physician for migraine headaches, hypertension, chronic pain, organic muscle abnormalities, chronic anorectal dysfunction associated with incontinence and constipation, or chronic pelvic muscular dysfunction associated with urinary incontinence.
  • Chiropractic care, when performed by a Doctor of Chiropractic (D.C.) and limited to traditional chiropractic services which include the initial physical examination, subsequent chiropractic manipulations and x-rays of the spine when medically necessary. No benefits will be paid for any other diagnostic tests performed or ordered by a chiropractor or for cervical traction units and other supplies or equipment prescribed by a chiropractor even if he or she is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
  • Occupational therapy when performed by an Occupational Therapist, Registered (O.T.R.).
  • Osteopathic manipulative therapy when performed by a Doctor of Osteopathy (D.O.).
  • Physical therapy and physical medicine when performed by a Registered Physical Therapist (R.P.T.), Medical Doctor (M.D.), or Doctor of Osteopathy (D.O.).
  • Speech/voice therapy when performed by a Speech/Language Pathologist provided the services are not part of an educational program.
  • Vision therapy when performed by a Doctor of Optometry (O.D.), including developmental vision therapy.

The Plan does not consider the fees of health clubs, masseurs, masseuses, fitness instructors, dance therapists, colon hydrotherapists or similar practitioners, even when recommended or prescribed by a doctor. Nor does it recognize the fees of medical assistant therapists, aides or other providers not specifically licensed by the state to render physical therapy, physical
medicine or rehabilitative therapy, even though they are operating under the supervision of a covered provider. The Plan does not consider the fees for rolfing, alexander technique, feldenkrais, bioenergetics, posture realignment, pilates therapy or yoga.

Plan's Allowance and Maximums for Therapy Benefits

The Plan has a maximum allowance it will consider for therapy benefits. The allowance depends on the type of therapy and whether you are using a network or non-network provider. In addition, the Plan has a maximum number of visits for certain types of therapy. The chart below outlines these allowances and maximums.

Therapy Network Allowance Non-Network Allowance Maximum Visits Per Quarter
Acupuncture Contract Allowance $55 per visit 8 visits*
Biofeedback Contract Allowance $55 per visit 9 visits
Chiropractic $45 per visit $45 per visit 12 visits*
Physical, Occupational and Osteopathic Contract Allowance $65 per visit None
Speech and Vision Contract Allowance $55 per visit None

* The Plan will not consider more than 12 outpatient sessions every calendar quarter for any combination of acupuncture and chiropractic treatment. In addition, visits for occupational, osteopathic, physical, speech and vision therapy will count toward the 12-visit quarterly maximum. For example, if you use five physical therapy visits during a calendar quarter and then want to visit a chiropractor, you would have seven visits available for the remainder of that quarter.


The Plan will also consider one initial medical exam per type of therapy for the doctor or therapist who is providing treatment. For physical therapy and physical medicine, the Plan will consider a second medical exam. Additional exams for all types of therapies except chiropractic will only be considered if there is a significant change to the patient's condition that warrants a re-examination. This determination will be based on a review of medical records by the Plan's medical consultants.

Preventive and Wellness Benefits

The Plan provides two levels of benefits for routine care: preventive benefits and wellness benefits. Preventive benefits are for services identified by the Affordable Care Act that are to be covered without cost sharing (deductible, copay or coinsurance) when rendered by a network provider. Wellness benefits apply to routine care services not identified as preventive by the Act and may be subject to the deductible, copay and coinsurance.

Preventive Benefits – Network Providers Only

The Affordable Care Act requires the Plan to cover certain preventive services received from network providers with no deductible, copay or coinsurance. The Plan will cover these preventive services whether they are performed separately or in the course of an annual physical. However, to avoid cost sharing the primary purpose of your office visit must be for
preventive care.

Cost sharing is permitted for an office visit involving a preventive service if the office visit is billed separately or the primary purpose of the office visit is not the preventive service. For example, if you go to a network provider for a sore throat, and while there it is recommended that you have your cholesterol checked, the office visit is subject to the deductible, copay and coinsurance and the cholesterol test is paid at 100%. Conversely, if you are diagnosed with a condition such as high cholesterol and your doctor performs a cholesterol test, then that test is subject to cost sharing as it is in connection with a medical condition.

The list of covered preventive services appears below. It may be updated by the federal government from time to time. Many of these services are provided during a routine physical, well-child, well-woman or well-man exam. Routine physicals, well-woman exams and well-man exams are limited to one per calendar year. Well-child exams are also limited to one per calendar year after age 4, although more frequent exams may be covered before that age.

Covered Preventive Care Services as Required by the Affordable Care Act
Newborns
  • Gonorrhea preventive medication for eyes of all newborns
  • Screening all newborns for:
    – Hearing loss – Sickle cell disease
    – Hypothyroidism – Phenylketonuria (PKU)
Childhood/Adolescent Immunizations
  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type B
  • Hepatitis A and B
  • Human Papillomavirus (HPV)
  • Inactive Poliovirus
  • Influenza (Flu)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal (pneumonia)
  • Rotavirus
  • Varicella (chickenpox)
Childhood
  • Autism screening for children at 18 and 24 months
  • Behavioral assessment for children of all ages
  • Blood pressure screening
  • Developmental screening for children throughout childhood
  • Dyslipidemia screening for children at higher risk of lipid disorder
  • Fluoride supplements for children without fluoride in their water – Fluoride supplements require a doctor's prescription and are covered under the Express Scripts prescription drug benefits.
  • Height, weight and BMI measurements
  • Hematocrit or Hemoglobin screening
  • Iron supplements for children 6 to 12 months at risk for anemia – Iron supplements are covered under the medical benefits and require a doctor's prescription in order to be considered for coverage.
  • Lead screening for children at risk of exposure
  • Medical history for all children throughout development
  • Obesity screening and counseling
  • Oral health risk assessment for young children
  • Tuberculin testing for children at higher risk of tuberculosis
  • Vision screening when performed during the course of a routine pediatric visit
Additional Screenings for Adolescents
  • Alcohol and drug use assessment
  • Cervical dysplasia screening for sexually active young women
  • Depression screening
  • HIV screening for adolescents at higher risk
  • Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
Adults
  • Alcohol misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease – Aspirin is covered under the medical benefits provided you have a doctor's prescription and you meet the age and risk criteria.
  • Blood pressure screening
  • Cholesterol screening for men age 35 or older, women age 45 or older, and younger adults at higher risk
  • Colorectal cancer screenings including fecal occult blood testing, sigmoidoscopy or colonoscopy for adults age 50 or older
  • Depression screening
  • Diabetes screening for type 2 diabetes for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for sexually active women and adults at higher risk
  • Obesity screening and counseling
  • Sexually transmitted infection (STI) prevention counseling for adults at higher risk
  • Syphilis screening for adults at higher risk
  • Tobacco use screening
Adult Immunizations
  • Diphtheria, Tetanus, Pertussis
  • Hepatitis A and B
  • Herpes Zoster (Shingles)
  • Human Papillomavirus (HPV)
  • Influenza (Flu)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal (pneumonia)
  • Varicella (chickenpox)
Additional Screenings for Men
  • Abdominal aortic aneurysm one-time screening for men age 65 to 75 who have smoked
Additional Services and Screenings for Women
  • BRCA counseling about genetic testing for women at higher risk
  • Breast cancer chemoprevention counseling for women at high risk for breast cancer
  • Breast cancer mammography every 1 to 2 years for women age 40 or older
  • Cervical cancer pap test for women
  • Chlamydia infection screening for younger women and women at higher risk
  • Contraception – FDA-approved contraception methods, sterilization and contraceptive counseling. Contraceptives that require a doctor's prescription are covered under the Express Scripts prescription drug benefits. Contraceptives that are administered in the doctor's office or that are available over-the-counter are covered under the medical benefits. Over-the-counter items require a doctor's prescription in order to be considered for coverage. Condoms are not covered.
  • Domestic violence screening and counseling
  • Gonorrhea screening for women at higher risk
  • Human Papillomavirus (HPV) DNA testing every three years for women age 30 or older
  • Osteoporosis screening for women age 60 or older, depending on risk factors
  • Well-woman visits
Specifically for Pregnant Women
  • Anemia screening for iron deficiency
  • Bacteriuria urinary tract infection screening
  • Breastfeeding support, supplies and counseling
  • Folic acid supplements for women who may become pregnant – Folic acid supplements are covered under the medical benefits and require a doctor's prescription in order to be considered for coverage.
  • Gestational diabetes screening
  • Hepatitis B screening during the first prenatal visit
  • Prenatal visits
  • Rh incompatibility blood type screening

Wellness Benefits

Not all routine services are included in the Affordable Care Act's preventive services list. The Plan considers these procedures under the wellness benefits.

Plan I

Wellness benefits for Plan I participants and their dependents are not subject to the medical deductible. You may see the doctor of your choice, in or out-of-network, subject to the appropriate copay and coinsurance. The Plan will consider generally accepted standards of medical practice for routine procedures such as the following:

  • Bone density tests for women under age 60 and for men – One per calendar year. Bone density tests for women age 60 or older are covered under preventive benefits.
  • Chest x-ray.
  • Complete blood count.
  • EKG.
  • Mammograms for women under age 40 – One per calendar year. Mammograms for women age 40 or older are covered under preventive benefits.
  • Travel immunizations – If no office visit is billed, no copay applies for network providers. The coinsurance does apply for network and non-network providers.
  • Urinalysis.

Plan II

  • Network Providers – Network wellness benefits for Plan II participants and their dependents are not subject to the medical deductible, although the copay and coinsurance do apply. The Plan will consider the following wellness services:
    • Bone density tests for women under age 60 and for men – One per calendar year. Bone density tests for women age 60 or older are covered under preventive benefits.
    • For individuals age 40 or older, generally accepted lab work and diagnostic tests for a routine physical such as a chest x-ray, complete blood count, EKG or urinalysis.
    • For children under the age of six, generally accepted lab work and diagnostic tests for a well-child care visit, such as a urinalysis and a complete blood count. Exception: In areas where no network providers are available, the Plan will consider well-child care provided by non-network providers.
    • Mammograms for women under age 40– One per calendar year. Mammograms for women age 40 or older are covered under preventive benefits.
    • Travel immunizations – If no office visit is billed, no copay applies. The coinsurance does apply.
  • Non-Network Providers – Non-network wellness benefits for Plan II participants and their dependents are subject to the medical deductible and coinsurance. The Plan will only consider the following non-network wellness services:
    • Bone density tests.
    • Mammogram (limited to one per calendar year unless diagnosis exists).
    • Pap test (limited to one per calendar year unless diagnosis exists).
    • Routine colonoscopy once every 10 years starting at age 50.

Outpatient Nursing Benefits

For private duty outpatient nursing services, the Plan's benefit is limited to 672 hours per person per calendar year. For example, this is equivalent to 28 days of nursing at 24 hours per day, or 56 days at 12 hours per day. The number of days of nursing allowable depends on the number of hours of nursing required per day. The allowance does not need to be used all at one time.

For example: If you use 150 hours of nursing at the beginning of the year, the balance of 522 hours is available for the remainder of the calendar year. Private duty nursing in excess of the 672 hours may be considered by case management. Because the nursing benefit contains several restrictions, as described below, you should obtain approval before services are rendered. The amount allowed per visit will be determined by the Plan's Reasonable Charge guidelines.

The Plan does not cover inpatient private duty nursing services under any circumstances.

Obtaining Approval for Private Duty Outpatient Nursing Care

Private duty nursing at home may be covered if you obtain advance approval as follows:

  • The nursing services must be prescribed by your doctor as medically necessary for treatment of an illness or injury that is covered by the Plan.
  • The level of nursing care must require a registered nurse (R.N.), licensed vocational nurse (L.V.N.), licensed practical nurse (L.P.N.) or equivalent state license who is not a relative or
    resident of your home.
  • The nursing must not be for custodial or longterm care. (See Glossary on page 107.)
  • The doctor must submit a written diagnosis and treatment report within 14 days of the start of nursing services.
  • Nursing notes must be submitted for review as claims are filed.

Medical consultants for the Plan will review the doctor's report and nursing notes. If the nursing care is approved, the Plan will specify the number of days that it will cover, and the amount per visit that it will allow.

If your doctor prescribes private duty nursing care, please contact the Plan Office as soon as possible.

Services by Christian Science practitioners are not recognized as nursing services.

Case Management

One of the Health Plan's most important tools in providing benefits for individuals with catastrophic illness or injury is the case management program. Case management offers a personal approach by which a coordinator works with the patient, the family and the attending physician to develop an appropriate treatment plan and to identify and suggest alternatives to
traditional inpatient hospital care.

Some services that are not normally covered under the medical benefits may be considered under the case management program. These include, but are not limited to, home nursing services, home physical and/or occupational therapy and durable medical equipment. Long term custodial care is not covered under the hospital benefits, the medical benefits or case management. All services and equipment must be pre-authorized by the case management team.

The case management team at the Plan Office utilizes case management nurses to assist in approving and arranging necessary services and equipment, locating appropriate providers and negotiating rates with non-network providers where there are no network providers available.

Case management can help with a wide variety of catastrophic illnesses and injuries including burns, spinal cord injuries, multiple trauma injuries, cancer, cardiovascular disease, stroke, joint replacement post-surgical care, acquired immune deficiency syndrome, cerebral palsy and multiple sclerosis. The case management team can also assist in arranging hospice care. If you feel the case management program is appropriate for your care you should contact the Plan Office as soon as possible.

The case management program is totally voluntary. Its purpose is to benefit the patient. Accordingly, if the patient, the physician and the family do not agree that the alternative plan is to the patient's benefit, the patient does not have to participate. The program is provided as part of the benefit plan so there is no additional cost to participants or their eligible dependents.

Non-Covered Medical Expenses

(Includes all Practitioners)

  • Acupuncture – Diagnostic services ordered or performed by a Certified Acupuncturist or supplies and equipment prescribed by a Certified Acupuncturist even if the provider is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
  • Applied behavioral analysis.
  • Charitable hospitals – Treatment received in charitable hospitals.
  • Chiropractic care – Diagnostic services ordered or performed by a chiropractor, (except spinal x-rays) or supplies and equipment prescribed by a chiropractor even if he or she is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
  • Condoms.
  • Cord blood harvesting and storage charges.
  • Cosmetic surgery and procedures, except where otherwise noted (see page 40 under "Medical Benefits" and page 44 under "Cosmetic Surgery and Other Cosmetic Procedures").
  • Custodial care – Treatment received in custodial, convalescent, educational, rehabilitative care or rest facilities.
  • Custodial nursing services.
  • Cytotoxic testing.
  • Dental services or appliances.
  • Durable medical equipment – A second or duplicate piece of approved durable medical equipment for travel or convenience purposes.
  • Electrolysis.
  • Environmental equipment such as air filters, humidifiers and nonallergic bedding.
  • Equipment and procedures not approved by the Food and Drug Administration.
  • Exercise equipment, whirlpools, sunlamps, heating pads and other similar general use items, whether or not prescribed by your doctor.
  • Food allergy antigens.
  • Food supplements, herbs, minerals, vitamins and other nutritional supplements.
  • Foot care – Routine foot care (removal of corns and calluses or cutting of nails) is not covered except when prescribed by a doctor who is treating you for a metabolic, neurologic or peripheral vascular disease such as diabetes or arteriosclerosis.
  • Gestational surrogate – Charges for services rendered to a gestational surrogate or to a fetus implanted into a gestational surrogate.
  • Glasses, contact lenses or eye refractions (except following covered eye surgery as described on page 40 or as provided through VSP as described on pages 67 and 68).
  • Growth hormones (except when pre-approved by the Plan under the prescription drug benefit as outlined on page 59).
  • Health clubs, rolfing, alexander technique, feldenkrais, bioenergetics, posture realignment, pilates therapy or yoga.
  • Homeopathic remedies.
  • Hypnosis or hypnotherapy.
  • Infertility treatment – Charges in connection with achieving and maintaining pregnancy.
  • Inpatient private duty nursing.
  • Intraoperative neurophysiologic monitoring, except in limited cases where the Plan's consultant determines that it is medically necessary.
  • Learning disabilities – Charges in connection with learning disabilities and academic accommodations.
  • Masseurs, masseuses, Massage Therapists (M.T.), Oriental Medical Doctors (O.M.D. or D.O.M., one who practices oriental medicine), fitness instructors, dance therapists or colon
    hydrotherapists.
  • Medical assistant therapists, aides or other providers not specifically licensed by the state to render physical or rehabilitative therapy, even though they are operating under the supervision of a covered provider.
  • Medical necessity – Services or supplies not recognized as generally accepted medical practice or necessary for diagnosis or treatment.
  • Modifications to a home or automobile to accommodate illness or injury.
  • Multifocal intraocular lens (IOL) implanted during cataract surgery that corrects presbyopia and astigmatism. The Health Plan covers cataract surgery and a standard (monofocal) IOL.
  • Naturopathic services, even if the provider is duly licensed in any state and authorized to provide medical services, including diagnostic tests performed or ordered by a naturopath. Naturopathic services include conventional diagnosis, therapeutic nutrition, botanical medicine, homeopathy, naturopathic childbirth attendance, classical Chinese medicine, hydrotherapy, manipulation, pharmacology and minor surgery.
  • Oral and topical medications dispensed in a physician's office.
  • Over-the-counter pregnancy tests.
  • Personal comfort items while hospitalized, such as TV or telephone.
  • Pregnancy for dependent children including elective termination of pregnancy (prenatal care from a network provider and complications of pregnancy are covered).
  • Reversal of vasectomy or tubal ligation.
  • Sleep Number beds.
  • Smoking cessation programs.
  • Surgical correction of a bite defect.
  • Surgical procedures to correct a refractive error such as LASIK, photorefractive keratectomy (PRK), radial keratotomy or radial thermocoagulation (RTK).
  • Weight control or weight loss programs, regardless of any underlying medical condition for which they may be prescribed.

See also "General Exclusions" on page 72.