MEDICAL BENEFITS

The Plan will pay a percentage of a preferred provider’s negotiated rate or a percentage of usual and customary charges for a non-preferred provider up to the amounts shown in the Schedule of Benefits charts starting on page 1. The following services and supplies are covered when ordered by a licensed provider, determined to be medically necessary by the Plan, and provided in accordance with Plan rules:

1. Hospitalization;
2. Services and supplies furnished by a hospital;
3. Services provided by a licensed physician or surgeon or other licensed healthcare professional approved by the Plan. However, if more than one operation is performed in the same operative field at one session, payment will not exceed the amount for the operation with the highest limit;
4. When multiple outpatient services are incurred on the same day and services overlap in any respect, the Plan will pay only for the service code that is most inclusive;
5. Services and treatment by a physical therapist, when prescribed in writing by a physician. The maximum benefit is $3,000 per year;
6. Anesthetics and their administration;
7. Dental treatment by a physician, dentist or dental surgeon for a fractured or dislocated jaw or for accidental injury to natural teeth including replacement of such teeth, and for cutting procedures in the mouth other than for extractions, repair and care of teeth and gums;
8. Lab and diagnostic services. CT scans, MRIs, PET scans and non-obstetrical scans including ultrasound will not be covered unless Pre-Certification is obtained from the Plan or in an emergency;

9. Genetic metabolic pharmacologic testing, when Pre-Certified by the Plan (except that amniocentesis does not require Pre-Certification). Requests for coverage of genetic testing must include the planned treatment based on the results;
10. Professional local ambulance service to the hospital for confinement therein and emergency transportation by regularly scheduled airline or railroad or by air ambulance from the place you become disabled, to the nearest hospital qualified to provide the special treatment for the injury or sickness;
11. Rental (or purchase, if the cost is less than the rental for the period required) of durable medical equipment such as a wheelchair or hospital bed for therapeutic treatment of a covered illness or non-work related injury, and that is:
1. Of no further use when medical needs end,
2. Usable only by the patient,
3. Not primarily for the comfort or hygiene of the patient, or solely to aid the care giver,
4. Not for environmental control,
5. Not for exercise,
6. Manufactured specifically for medical use,
7. Approved as effective and usual and customary treatment of a condition as determined by the Plan, and
8. Not for prevention purposes;
Durable medial equipment costing over $1,000 is not covered unless Pre-Certified by the Plan.
12. Artificial limbs or eyes;
13. Orthotics when ordered by your medical doctor and made specifically for your personal use, up to $400 per pair: (a) for adults, no more than one pair every four years; (b) for children up to age 19, no more than one pair for every two full shoe size increases,
14. Charges incurred for prosthetic devices to restore a method of speaking incidental to a laryngectomy. Covered medical expenses will include the initial and subsequent prosthetic devices or installation accessories, as ordered by the physician, but will not include electronic voice producing machines;
15. Wigs, when Pre-Certified by the Plan and required as the result of a disease or the treatment of a disease which is covered by the Plan, at 90% of cost up to a maximum benefit of $500 every three years;
16. Drugs and medicines while hospital confined;
17. Blood and blood plasma if the blood is not replaced;
18. Charges incurred for the treatment of osteoporosis. Covered expenses will include all Food and Drug Administration (FDA) approved technologies, including bone mass measurement technologies as deemed medically appropriate by a physician;
19. Pregnancy benefits for:
1. Charges in connection with normal pregnancy and delivery for female employees and spouses, but not for dependent daughters, and
2. Charges in connection with complications of pregnancy are covered in all cases, and
3. Charges for any hospital length of stay in connection with childbirth for the mother or newborn child up to 48 hours following a normal vaginal delivery, or 96 hours following a cesarean section. The attending provider of a mother or newborn, after consulting with the mother, is not prohibited from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). The Plan does not require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods;
   Prenatal care management services are available and can be obtained by calling one of the Plan’s nurse case managers at (800) 515-2073. The Administrative Office may also contact you directly regarding these services.
20. Mastectomy Benefits: If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Woman's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and patient for:
    1. All stages of reconstruction of the breast on which the mastectomy was performed;
    2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
    3. Prostheses and treatment of physical complications of the mastectomy, including lymphedemas.
    These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.
21. Voluntary sterilization charges by a hospital and/or physician for sterilization of the reproductive system of the employee or dependent spouse;
22. Voluntary termination of pregnancy, for employees and dependent spouses;
23. Eye refractions only if required because of accidental injury to the eyes, within one year of the accident (a separate vision benefit is described on page 41);
24. Chiropractic treatment, as defined in this booklet, up to a maximum payment of $1,500 per calendar year, including x-rays relating to chiropractic treatment and massage therapy provided by a licensed message therapist as part of a written chiropractic treatment plan;

25. Well-baby exams, well-child exams and childhood immunizations, from birth to the second birthday and one exam per year from age two through 19, including appropriate laboratory services and routine immunizations;
26. Individuals age 20 through 64 are covered for one routine exam every two years and individuals over age 65 are covered for one routine exam per year, plus immunizations;
27. PAP smears and pelvic exams;
28. Mammography for screening and diagnostic purposes every two years or more frequently based on a physician’s recommendation;
29. Home health care is covered as shown in the Schedule of Benefits. Services for home health care are covered only when Pre-Certified by the Plan. The Plan will pay for charges for the following home health care services that begin within 14 days of a hospital discharge, are due to the same injury or illness for which the patient was hospitalized, and are provided under a written plan approved by the attending physician instead of hospital confinement:
1. Part-time or intermittent skilled nursing care by a registered nurse, or by a licensed vocational nurse under the supervision of a registered nurse, if the services of a registered nurse are not available;
2. Part-time or intermittent home health aid services that consist primarily of supportive service under the supervision of a nurse or physical, speech or occupational therapist;
3. Physical, occupational or speech therapy; and
4. Medical supplies, drugs and medications prescribed by a physician, related pharmaceutical services and laboratory services to the extent such items would have been covered had the patient been hospitalized.
Home health care benefits are payable for up to 100 home health care visits per year. Each visit by a home health care team shall be considered as one visit. A visit of four hours or less by a home health aide shall be considered one visit.


No benefits are payable for home health care services or supplies that are:
1. Not included in the physician’s written treatment plan;
2. Provided by a person who lives with the patient or is a member of the patient’s family or spouse’s family;
3. Provided during any period in which the patient is not under the continuing care of a physician;
4. Custodial care; and
5. Transportation, except ambulance services as specifically provided.
30. Charges for hospice care are covered under the Plan as shown in the Schedule of Benefits. Hospice services are covered only when Pre-Certified by the Plan.

    Charges for hospice care are covered up to $15,000 for the following services:
    
    Inpatient hospice care including:

1. room and board at a rate not to exceed the hospital’s daily semiprivate room rate,
2. physician and skilled nursing services,
3. respiratory therapy and life support system,
4. pain relief therapy,
5. drugs and medicines, and
6. psychological counseling and spiritual support services;
Outpatient care, including:
1. intermittent nursing care by nurses,
2. visits by full-time hospice employees,
3. physical and respiratory therapy,
4. oxygen and equipment,
5. rental of wheelchairs,
6. hospital beds and other medical equipment,
7. medicines and drugs,
8. homemaker services; and
9. professional counseling sessions with the patient’s family during the period of hospice care and during the three month period following the patient’s death.