Download The Health Plan Schedule of Benefits

XIX.
SCHEDULE OF BENEFITS.
Benefits are subject to a contract year deductible that must be paid by the member before benefits are
payable under this plan. Only expenses that you and your eligible dependents incur for covered services
count toward satisfying your annual deductible. To help employees with several covered dependents, the
deductible you pay for the entire family, regardless of family size, is specified as a family deductible
maximum. To meet the family deductible maximum, you can count the eligible expenses incurred by two
or more family members.
Primary care physician (“PCP”), Ob/gyn physician, specialty physician (including secondary care
physician (“SCP”), mental health and substance abuse office visits, certain diabetic services, and
emergency room and urgent care visits require a copay which is separate from the deductible.
Individual
Family
Deductible Maximum
The deductible amount contributed by any one family member shall not exceed that of an
individual annual deductible maximum amount.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
To determine the maximum amount of expenses you or your family can incur in one year, refer to the
annual out-of-pocket maximum listed below. Expenses you incur for copays, not to include supplemental
services (i.e., prescription copays) count toward satisfying the out-of-pocket maximum. Expenses you
incur for satisfying your annual deductible do not accumulate toward your annual out-of-pocket maximum.
The annual out-of-pocket maximum shall not exceed 200% of the average annual premium cost for the
member.
Individual
Family
Annual Out-of-Pocket Maximum
The copay amount contributed by any one family member shall not exceed that of an individual
annual out-of-pocket maximum amount.
Copays paid by a member on any single covered basic health care service during a contract year shall
not exceed 40% of the average cost to the Plan to provide the service. Average cost to the Plan is that
amount paid by the Plan for a particular service during the previous calendar year derived by dividing the
total amount paid by the number of services provided.
The annual out-of-pocket maximum refers to the amount of money you pay out of your pocket for eligible
health care expenses. Copays, both fixed dollar amounts and percentages, which you pay for covered
services, count toward your out-of-pocket maximum. There is an annual individual out- of-pocket
maximum and an annual family out-of-pocket maximum. To meet the annual family out-of-pocket
maximum, you can count the annual eligible expenses incurred by two or more family members. Please
remember that expenses you incur to satisfy your annual deductible do not count toward the annual outof- pocket maximum.
SERVICES REQUIRING PREAUTHORIZATION
Admissions (elective)
Tertiary Care
Hysterectomy
Imaging (PET, PET-CT Fusion, SPECT of Brain)
Chiropractic Care
Podiatric Care
Audiology
Hyperbaric Oxygen
TMJ Care
All Genetic Testing
Urinary/Fecal Incontinence Treatment
Wound Care Clinic
All Out-of-Area Wound Care Clinic
Bariatric Surgery
Cosmetic Procedure
Varicose Vein Treatment
Botox Injections
Infertility
Speech Therapy
Home Health Services
Hospice
Home Infusion Therapy
Durable Medical Equipment:
Greater than $500
Non-Emergent Ambulance
Behavioral Health Services (except
when related to biologically based
mental illnesses)
Addictionology
:
Other services may require Preauthorization. If you, or your physician, have a question regarding
Preauthorization, please contact a Plan Customer Service Representative at St. Clairsville/Morgantown
areas: (740) 695-7902, (888) 847-7902, TDD: (740) 695-7919, (800) 622-3925, Massillon area: (330)
837-6880, (800) 426-9013 or TDD (877) 236-2291.
NOTE: TRUE EMERGENCY OR URGENT CARE SERVICES ARE COVERED WITHOUT REGARD TO
PREAUTHORIZATION.
HELP US HELP YOU!
Help stop insurance fraud. Each incident uncovered and stopped saves you and every other policyholder
money. That is as important to us as it is to you. Health care fraud usually takes the form of false or
misleading claims for payment submitted to insurance carriers and health care plans. Local and toll-free
“FRAUD” hotline phone numbers are now available. If at any time you may have concerns or questions
about charges or payments made for you or an eligible dependent, feel free to call the Plan’s Fraud
Hotline at (740) 699-6111 or (877) 296-7283.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
BENEFIT DESCRIPTION
These services are covered when they meet Plan
guidelines, are provided or arranged for by a Plan physician,
deemed medically necessary and appropriate, and
approved by the Plan. There may be specific limitations
(see “Limitations and Exclusions”).
MEMBER COST
MEMBER COST
PLAN WITH NO
DEDUCTIBLE
PLAN WITH
DEDUCTIBLE
INPATIENT HOSPITAL SERVICES
•Hospitalization: semi-private room, ICU/CCU,
nursing care, maternity and birthing room (48 hrs.
normal, 96 hrs. cesarean), nursery, operating room,
therapy (oxygen and respiratory, physical,
occupational and speech), laboratory, therapeutic and
diagnostic x-ray, observation bed, other services and
supplies
$0
$0 (after deductible)
•Physician visits and services
$0
$0 (after deductible)
•Rehabilitation
$0 days 1-30, 20%
copay/days 31+
$0 days 1-30, 20%
copay/days 31+ (after
deductible)
•Skilled Nursing Facility: limited to a maximum of
120 days per contract year and/or per qualifying
diagnosis per lifetime, (there may be instances where
a non-contracting facility may be covered, for
additional information call St. Clairsville/Morgantown
areas: (740) 695-7902, (888) 847-7902, Massillon
area: (330) 837-6880 or (800) 426-9013.
$25 copay/day
$25 copay/day (after
deductible)
•Audiology: audiological exam, one per contract year
$15 copay/visit
$15 copay/visit
(deductible waived)
•Chiropractic care: limited services, subject to Plan
review, limited to a maximum of 20 visits per contract
year
•Maternity care: pre and post-natal care/obstetrical
services*
$15 copay/visit
$15 copay/visit
(deductible waived)
$15 copay/initial visit
only
$15 copay/initial visit
only (deductible waived)
•Ob/gyn care
$15 copay/visit
$15 copay/visit
(deductible waived)
•Podiatry care
$15 copay/visit
$15 copay/visit
(deductible waived)
PHYSICIAN OFFICE VISITS
*Post delivery follow-up visits: 48 hrs. normal, 96 hrs.
cesarean, if mother and physician determine that the
hospital stay is to be shortened, 72 hrs. of follow-up care will
be provided at no charge and deductible waived
BENEFIT DESCRIPTION
These services are covered when they meet Plan
guidelines, are provided or arranged for by a Plan physician,
deemed medically necessary and appropriate, and
approved by the Plan. There may be specific limitations
(see “Limitations and Exclusions”).
MEMBER COST
MEMBER COST
PLAN WITH NO
DEDUCTIBLE
PLAN WITH
DEDUCTIBLE
•Primary care physician (“PCP”)
$15 copay/visit
$15 copay/visit
(deductible waived)
•Specialist care
$15 copay/visit
$15 copay/visit
(deductible waived)
$0
$0 (deductible waived)
20% copay
20% copay (after
deductible)
$0 (after deductible)
DIABETIC COVERAGE (Treatment and/or
management for insulin or non-insulin dependent
diabetes, diabetes during pregnancy or those
known to have risk factors)
•Annual retinal exam by Optometrist or
Ophthalmologist*
* If the exam reveals an abnormal condition, future
treatment may require Preauthorization and
applicable member costs will apply
•Insulin pumps and pump supplies: covered under
DME benefit, limited to the Plan’s basic allowance
•Laboratory*
* The Plan and the American Diabetes Association
recommend fasting blood glucose, lipid profile at least
annually, glycosylated hemoglobin (HbA1c) at least
twice per year, microalbuminuria at least annually
•Pharmacological agents: 31-day supply dispensed
monthly, subject to formulary*
$0
$10/30% whichever is
greater/copay
$10/30% whichever is
greater/copay
(deductible waived)
* Members covered under a prescription drug rider will
receive pharmacological agents through their
prescription drug rider unless the benefits supplied
through the rider are at a lesser level, all agent
expenses will accumulate toward the annual
prescription maximum, further coverage after the
maximum is reached requires Preauthorization. Nonformulary agents will be covered only if a specific
medical indication exists whereby the listed formulary
agents cannot be used and requires
Preauthorization.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
BENEFIT DESCRIPTION
These services are covered when they meet Plan
guidelines, are provided or arranged for by a Plan physician,
deemed medically necessary and appropriate, and
approved by the Plan. There may be specific limitations
(see “Limitations and Exclusions”).
MEMBER COST
MEMBER COST
PLAN WITH NO
DEDUCTIBLE
PLAN WITH
DEDUCTIBLE
•Self management education services: limited to
16 visits (maximum of eight individual and eight
group) per contract year, medically appropriate
education on proper self-management, treatment and
diet
$0
$0 (deductible waived)
•Supplies: glucometers, syringes, lancets, glucose
test strips, alcohol swabs, carp-u-jet, urine ketone
testing strips and penlets*
$0
$0 (deductible waived)
•Allergy injections
$0
$0 (after deductible)
•Ambulance service: emergency transportation,
medically necessary only *
$25 copay/incident
$25 copay/incident
(after deductible)
$25/30% whichever is
less/copay/incident
$25/30% whichever is
less/copay/incident
(after deductible)
•Biofeedback therapy: for urinary or fecal
incontinence only
•Cardiac rehabilitation: limited to a maximum of 12
weeks or 36 visits per heart attack or heart surgery
30% copay/visit
30% copay/visit (after
deductible)
$0 (after deductible)
•Durable medical equipment (DME) and DME
supplies: rental or purchase is the option of the Plan,
limited to Plan’s basic allowance
•Emergency care: copay waived if admitted
20% copay
20% copay (after
deductible)
$50 copay/incident
•Family planning: contraceptive injections (such as
Depo Provera), IUD, diaphragm
30% copay/visit/injection
$50 copay/incident
(deductible waived)
30% copay/visit/injection
(after deductible)
•Home health: services for intermittent skilled care
only (home health aide not covered)
•Home IV therapy/infusion therapy
$0
$0 (after deductible)
$0
$0 (after deductible)
•Hospice care
$0
$0 (after deductible)
* Supplied through pharmacies
OTHER SERVICES (PHYSICIAN’S OFFICE,
HOSPITAL, HOME SETTING, OTHER PLAN OR
APPROVED PROVIDER)
Note: applicable office visit copay may apply
*Scheduled transportation will be reviewed for medical
necessity and appropriateness
•Ambulette service: will be reviewed for medical
necessity and appropriateness
$0
BENEFIT DESCRIPTION
These services are covered when they meet Plan
guidelines, are provided or arranged for by a Plan physician,
deemed medically necessary and appropriate, and
approved by the Plan. There may be specific limitations
(see “Limitations and Exclusions”).
MEMBER COST
MEMBER COST
PLAN WITH NO
DEDUCTIBLE
PLAN WITH
DEDUCTIBLE
•Infertility services: limited to basic health care
30% copay/visit/injection
30% copay/visit/injection
(after deductible)
•Oral surgical services: accidental or injury only,
repair limited to gums only
•Orthotics: limited to Plan’s basic allowance
$0
$0 (after deductible)
20% copay
•Outpatient diagnostic and therapeutic services:
laboratory, radiology (to include MRI, MRA, CAT and
PET scans), diagnostic tests and therapeutic
treatments
$0
20% copay (after
deductible)
$0 (after deductible)
•Outpatient surgery: to include office setting
$0
$0 (after deductible)
•Preventive Care: injections, immunizations
(pediatric/childhood, adolescent and adult); annual
mammography, Pap smear, prostate, hearing
screening, child health supervision services (review of
physical and emotional status birth to age 9), physical
exam (one per calendar year) and well child care*
$0
$0 (deductible waived)
20% copay
20% copay (after
deductible)
•Pulmonary rehabilitation: limited to a maximum of
12 weeks or 36 visits per contract year
•Radiation and chemotherapy
$0
$0 (after deductible)
$0
$0 (after deductible)
•Specialty drugs: high cost medications used to treat
very specific diseases that require extensive
management for safety and effectiveness. These
drugs require Preauthorization and may be
dispensed through a pharmacy
30% copay
30% copay (after
deductible)
*In-office screenings and exams, office visit copay will
apply
•Prosthetic and prosthetic supplies: limited to
Plan’s basic allowance
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
BENEFIT DESCRIPTION
These services are covered when they meet Plan
guidelines, are provided or arranged for by a Plan physician,
deemed medically necessary and appropriate, and
approved by the Plan. There may be specific limitations
(see “Limitations and Exclusions”).
MEMBER COST
MEMBER COST
PLAN WITH NO
DEDUCTIBLE
PLAN WITH
DEDUCTIBLE
•Temporomandibular joint dysfunction (TMJ): nonexperimental, medically necessary services
30% copay/visit
30% copay/visit (after
deductible)
•Therapy (physical, occupational and speech):
short-term only, each limited to the lesser of
maintenance level not to exceed 20 visits per
occurrence
$15 copay/visit per
therapy type
$15 copay/visit per
therapy type (after
deductible)
•Urgent care: copay waived if admitted
$25 copay/incident
$25 copay/incident
(deductible waived)
$100 copay/admission
$100 copay/admission
(after deductible)
•Inpatient substance abuse rehabilitation: limited
to one treatment course per lifetime to a maximum
benefit of 30 encounters. Encounters are inpatient
hospital days, intensive outpatient hospital visits,
partial hospitalization visits or residential treatment
programs. Treatment programs may be combined
•Inpatient mental health treatment: inpatient
hospital days, intensive outpatient hospital visits,
partial hospitalization visits or residential treatment
programs. Treatment programs may be combined
•Outpatient substance abuse treatment: limited to
maximum of 30 visits per contract year
$200 copay/admission
$200 copay/admission
(after deductible)
$0
$0 (after deductible)
$20 copay/visit
$20 copay/visit
(deductible waived)
•Outpatient mental health treatment: office visits,
hospital outpatient department or licensed outpatient
treatment facility
OTHER INFORMATION
$15 copay/visit
$15 copay/visit
(deductible waived)
MENTAL HEALTH/SUBSTANCE ABUSE SERVICES
(The Plan has contracted with a Behavioral Health
Administrator (BHA) to administer mental health
benefits. To obtain mental health services, a member
may contact a mental health provider or contact the
Plan or our BHA for assistance, (877) 221-9295)
•Inpatient substance abuse detoxification: limited
to detoxification only
If services fall in more than one copay category the
higher copay shall be applicable
When services are limited to a maximum number of
days, treatments, visits, etc., each visit, treatment,
etc., must be medically necessary and appropriate to
be covered.
BENEFIT DESCRIPTION
These services are covered when they meet Plan
guidelines, are provided or arranged for by a Plan physician,
deemed medically necessary and appropriate, and
approved by the Plan. There may be specific limitations
(see “Limitations and Exclusions”).
MEMBER COST
MEMBER COST
PLAN WITH NO
DEDUCTIBLE
PLAN WITH
DEDUCTIBLE
Percentage copays are based on the amount paid,
allowed or negotiated by the Plan
Members are responsible for any financial obligations
for non-covered services
Certain covered diabetic pharmacological agents,
diabetic supplies, DME/DME supplies and specialty
drugs listed under “Benefit Description” are
considered prescription benefits. Should these
benefits be denied as non-covered by the member’s
prescription coverage, or if the member has no
prescription coverage, the Plan will process these
drugs/supplies as medical benefits as outlined in this
Schedule of Benefits. Please contact the Plan should
you have any questions.
Members with prescriptions coverage: prescriptions
prescribed for biologically based mental illnesses will
be covered under the same terms and conditions as
any other covered illnesses.
LIMITATIONS.
A. HOSPICE CARE.
Members who are diagnosed as having a terminal illness with a life expectancy of six months or less may
elect home-based hospice care. The focus in hospice is care, not a cure. Treatment is provided for
symptoms and pain management. Care must be provided by hospice provider under the supervision of a
physician and with participation of a Plan case manager.
B. PLASTIC SURGERY.
Plastic surgery procedures are covered ONLY for the reasons stated below:
Trauma/Accidental Injury Congenital Birth Defect.
Payment will be made for hospital/medical services incurred in connection with these conditions for
plastic surgery only under the following circumstances.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
• The requested procedure is required as a direct result of injury secondary to trauma or accident (i.e.
motor vehicle accident).
• The requested procedure is required to correct a congenital birth defect (i.e. cleft lip or palate).
• Surgery required as result of an injury caused by the act of a person convicted of a crime involving
family violence.
Coverage is subject to specific Plan restrictions.
Mastectomy/Breast Implants and Removal/Replacement of Implants.
Benefits for reconstructive surgery after a mastectomy will be covered under inpatient services by the
Plan. The following benefits are included:
iCoverage for reconstruction of the breast on which the mastectomy was performed.
iSurgery and reconstruction of the other breast to produce a symmetrical appearance.
iCoverage for prostheses and physical complications of all stages of the mastectomy, including
lymphedemas.
No payment is made for surgical procedures for insertion of breast implants unless it is necessary for
breast reconstruction with mastectomy specifically related to breast cancer or fibrocystic breast disease.
No payment is made for the removal/replacement of breast implants except for those inserted for
reconstructive purposes specifically related to mastectomy for breast cancer or fibrocystic breast disease.
Consideration will be given to those that have been deemed medically necessary by the Plan to
remove/replace.
C. ORAL SURGICAL SERVICES.
Oral surgical coverage is limited and will only be covered as indicated:
Mandible/Maxillary/Jaw Structure
Conditions related to malposition of the bones of the jaw are not covered (i.e., orthognathic procedures).
Impacted wisdom teeth and full mouth extraction.
Impacted wisdom teeth, full mouth extraction and general anesthesia are not covered.
Odontogenic dentigerous cysts.
Cysts that form in the mouth and/or jaw area will be covered only if they are medical (non-dental) in
nature. Preauthorization by the Plan is required.
Diseases of the gums, that are non-dental in nature and deemed medically necessary and appropriate,
are covered. Preauthorization by the Plan is required.
Accident/Injury.
Oral surgical and hospital services resulting directly from acute trauma or an accident/injury (i.e., car
accident) are limited to the following:
iCoverage is subject to specific Plan restrictions.
iServices must have been initiated and rendered within six months of the accident.
iOral surgical services are limited to repair of hard or soft tissues of the face excluding the direct repair
of teeth.
iMust require the expertise of an oral surgeon, be medically necessary and approved by the Plan.
Injuries to the gums, that are non-dental in nature and deemed medically necessary and appropriate, are
covered. Preauthorization by the Plan is required.
Congenital Birth Defects.
Payment will be made for medically necessary oral surgery and/or hospital/medical services to correct
congenital birth defects (not developmental) such as cleft lip or palate.
Coverage is subject to specific Plan restrictions.
D. SPECIALTY DRUGS.
Specialty drugs are those high cost medications including drugs manufactured by biotechnology.
Specialty drugs may be administered by injection, oral, transdermal, or inhaled. Specialty drugs are used
to treat very specific diseases and require extensive management for safety and effectiveness. Dosages
need to be monitored for effect and adjustments may be needed for adequate response to affectively
treat the disease.
Specialty drugs require complex dispensing techniques. Dispensing may be limited to pharmacies with
specific skills and distribution programs to assure proper delivery of these medications. Quantities limited
to a 31-day supply (other quantity limits may apply).
Specialty drugs require prior authorization to assure the patient is an appropriate candidate for the drug.
Approval periods for authorization may vary according to agent prescribed. Additionally, oversight is an
integral part of the prior authorization process. The Plan will monitor the use of the specialty drug for the
following.
•Dose optimization
•Proper disposal of ancillary material used in the
•Appropriate monitoring (including required lab studies) delivery of the medication (i.e., syringes)
•Patient compliance to prescribed therapy
•Drug interaction monitoring
EXCLUSIONS.
1. Hospital and medical services, or items, that are not medically necessary and/or appropriate as
determined by the Plan. Non-medical treatment, including special education and training for dyslexia,
global developmental delay, speech therapy for developmental delay of speech, mental retardation,
learning disabilities or behavioral disorders.
2. Cosmetic, plastic or reconstructive surgery or other services done primarily to improve, alter or
enhance appearance, salabraison, chemosurgery or other such skin abrasions procedures to remove
scars or tattoos or services related to body piercing (other than complications) whether or not for
psychological or emotional reasons, unless required by law. Cosmetic/plastic surgery is covered
only to correct conditions resulting from the following.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
(a) Acute trauma directly related to accidents/injury (i.e., car accident).
(b) Congenital defects (not developmental).
(c) Reconstructive surgery following a mastectomy.
Services must be deemed medically necessary and appropriate by the Plan. A second opinion may
be required. See “Limitations”.
3. Dental care (including plates, crowns, bridges, dental implants, endodontia, periodontia,
prosthodontia, orthodontia and dentistry). Extraction of all teeth including wisdom teeth regardless of
the cause and/or condition. Osteotomies of the maxilla or mandible (considered dental procedure)
regardless of the cause or condition, whether congenital or acquired.
Limited benefits exist for treatment to diseased gums and cysts or abscesses. See “Limitations”.
4. Custodial or domiciliary care, respite care, private duty nursing, intermediate care, home health aid
services, rest cures or other services primarily to assist in the activities of daily living and personal
comfort items.
5. Items or medical and hospital services deemed to be investigational or experimental by the Plan in
conjunction with its specialty consultants, appropriate governmental agencies and other regulatory
agencies as interpreted by the Plan. If medically acceptable and conventional techniques or treatment
are available, new ones may not be covered. At such time as these new procedures, techniques or
treatments become non-experimental or investigational and are medically necessary and appropriate,
then they may be covered.
6. If otherwise standard treatment items such as human tissues, anatomic structures and blood or blood
derivatives are prohibited in the treatment of an individual based only by non-medical considerations
(i.e., relating to religious restrictions or personal preferences) the alternative products used as
substitutes are not a covered benefit.
7. Private rooms except when medically appropriate and authorized by the Plan. Personal or comfort
items and services (i.e., guest meals and lodging, radio, television and phone).
8. Hospital or medical care for conditions that state or local law requires to be treated in a public facility.
9. Any injury or sickness to the extent any benefits, settlement, award or damages are received or
payable (or could reasonably be expected to be received or payable if claim was made) by reason of
Workers' Compensation, employer's liability or similar law or act. This provision applies even if you
have waived your rights to Workers’ Compensation, employer’s liability or similar laws or acts.
10. Reversal of voluntary sterilization and associated services and/or expenses.
11. Sex transformation surgery and associated services and/or expenses except when medically
necessary and appropriate. Procedures, services and supplies related to sexual dysfunction,
including but not limited to, penile implants.
12. Services not provided, arranged or authorized by your physician, except in an emergency or when
allowed in this Certificate. Elective pre-surgery testing on an inpatient basis without the authorization
of the Plan’s Medical Director.
13. Medical equipment, appliances, devices or supplies of the following types.
. Equipment or supplies that are mainly for patient comfort or convenience. Items such as
bathtub lifts or seats, massage devices, elevators, stair lifts, escalators, hydraulic van or car
lifts, orthopedic mattresses, walking canes with seats, trapeze bars, child strollers, lift chairs,
recliners, contour chairs, adjustable beds or back cushions.
. Exercise equipment such as exercycles, parallel bars, walking, climbing or skiing machines,
health spas and hydrospray jet injectors.
. Educational equipment including augmentive communication devices.
. Environmental control equipment such as air conditioners, humidifiers or dehumidifiers, air
cleaners or filters, portable heaters or dust extractors.
. Hygienic products or supplies and equipment such as bed baths and toilet seats.
. Whirlpool pumps or equipment.
. Supplies such as tape, alcohol, Q-tips/swabs, gauze, bandages, thermometers, aspirin,
diapers (adult or infant), heating pads or ice bags.
. Professional medical equipment such as blood pressure kits or stethoscopes.
. Nutritional products or supplements, food liquidizers or food processors and enterals.
. Wigs or wig styling, vibrators or bathroom scales.
. Home modifications or supplemental DME equipment, enhancers or modifiers beyond the
Plan’s basic allowance.
. Duplicate equipment or repairs to duplicate equipment; the replacement of medical equipment,
prosthetics or orthotics if required due to loss, theft or destruction.
. Limited replacement or repairs to medical equipment, prosthetics or orthotics only when required
because of wear or because of a change in the member’s condition.
. Any over the counter items such as stockings, collars or supports.
. Medic Alert bracelets/devices, Count-a-Dose magnifiers and insulin carrying devices.
. Replacement batteries for durable medical equipment.
14. Physical, psychiatric, or psychological exams, testing, or treatments not otherwise covered under the
Plan when such services are as follows.
. Related to employment or school.
. To obtain or maintain insurance.
. Needed for marriage or adoption proceedings.
. Related to judicial or administrative proceedings or orders.
. Conducted for purposes of medical research.
. To obtain or maintain a license or official document of any type.
. To participate in sports.
15. Infertility services are limited to basic health care services. This means diagnostic and exploratory
procedures to determine infertility including surgical procedures to correct medically diagnosed
disease or condition of the reproductive organs. Services must be deemed medically necessary by
the Plan.
Services such as in-vitro fertilization and gamete intrafallopian transfer (GIFT), zygote intrafallopian
transfer (ZIFT), embryo transport, surrogate parenting, donor semen, sperm washing, artificial
insemination, drugs (oral, topical or injectable) and experimental services are not covered.
16. Elective termination of pregnancy, except when determined medically appropriate.
17. Therapy and related services for a patient showing no progress. Speech therapy is not a covered
benefit except when medically indicated as a result of a congenital defect (i.e., cleft palate), stroke or
physical trauma.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
18. Acupuncture, acupressure, hypnosis, electrolysis, Christian Science treatment and autopsy. Any
education or training classes including Lamaze and smoking cessation. Patches for smoking
cessation, birth control implants (i.e., Norplant), Estrogen and Androgen pellet implants, paternity
testing, massage and vision therapy.
19. Liposuction, panniculectomies, abdominoplasty (i.e., surgical removal of fatty tissue), gastric stapling
and gastroplasty or any other surgical treatment for morbid obesity.
20. Work hardening programs including functional capacity evaluations.
21. Marriage counseling.
22. Routine foot care including the following.
. Cutting, trimming or partial removal of toenails.
. Treatment of flat feet, fallen arches or weak feet.
. Strapping or taping of the feet.
. Arch supports.
. To remove in whole or in part of the following.
(a) Corns, callouses (thickening of the skin due to friction, pressure or other irritation).
(b) Hyperplasia (overgrowth of the skin).
(c) Hypertrophy (growth of tissue under the skin).
. Hygienic and preventive maintenance care. This includes cleaning and soaking the feet and the use
of skin creams to maintain skin tone of either ambulatory or bedfast patients. Any other service
performed in the absence of localized illness, injury or symptoms involving the foot.
23. Weight loss services and associated expenses including but not limited to, surgical procedures, wiring
of the jaw, weight control programs, weight control drugs or products, nutritional products or
supplements, screening for weight control programs and services of a similar nature.
24. Safety devices. Devices used specifically for safety or to affect performance including sports-related
activities.
25. Hepatitis B vaccine coverage limited to “direct exposure” defined as transmission that occurs through
inadvertent percutaneous inoculation, mucosal absorption or sexual contact with a source currently
infected with acute Hepatitis B virus. Vaccines when related to occupation or occupational,
professional and educational requirements and dependent immunizations beyond their 21st birthday.
Injections and immunizations required for travel outside the USA and associated with natural disasters
(including Hepatitis A).
26. Organ transplants are covered (including transplant recipient’s reasonable travel and lodging
expenses) but limited to the following.
Liver.
Bone Marrow.
Heart/Lung.
Corneal.
Heart.
Lung.
Kidney.
Pancreas.
Bowel.
Transplants must be deemed medically necessary and appropriate by the Plan and meet Plan criteria.
Experimental and investigational transplants and related procedures (as determined by the Plan) are
not covered. Services and expenses related to all aspects of organ or tissue procurement rendered or
incurred prior to the presentation to the donee, including all donor expenses.
27. Optical services, routine vision exams/screenings (except for children through age 17 provided by a
physician), refractions, radial keratotomy and other surgery to correct vision, eyeglasses, contact
lenses and fittings unless otherwise provided by a supplemental rider.
28. Non-medical ancillary services and long-term rehabilitation services for the treatment of chemical
dependency.
29. Physical exams or medical care required by court order or obtained in anticipation of judicial action.
30. 0ther limitations that are specifically stated in the Schedule of Benefits of this document.
31. Prescription drugs, unless otherwise provided in a supplemental rider. Any over the counter
medications including but not limited to laxatives, antacids and vaginal yeast products.
32. Any services for which the Insured has no legal obligation to pay in the absence of this or similar
coverage.
33. Services rendered by a provider with the same legal residence as a covered person or who is a
member of the covered person’s family. This includes spouse, brothers, sister, parent or child.
Services received or rendered by a provider to themselves.
34. Services rendered outside the scope of a provider’s license.
35. Treatment in a state or federal hospital for military or service-related injuries or disabilities and/or
services furnished, with or without charge, by any government agency or program, including
incarceration, Medicare, military agencies, National Guard or Reserves.
36. Rehabilitation therapy that is primarily educational or cognitive in nature.
37. Non-medical services related to the treatment of Temporomandibular Joint Dysfunction (TMJ),
Craniomandibular Joint Dysfunction (CMD) and stylomandibular ligament including but not limited to
braces, non-invasive conditions, experimental procedures, splints or other appliances.
38 Podiatrists performing procedures are limited by the Plan guidelines in accordance with experience,
training and certification.
39. Services that in the judgment of your physician are not medically appropriate or not required by
accepted standards of medical practice or the Plan rules governing services.
40. Hearing aids or Cochlear implant systems. Hearing exams unless there is a medical condition that
requires such exam.
41. Megavitamin therapy, psychosurgery and nutritional based therapy.
Any questions or problems, please call or write our Customer Service Department at:
St. Clairsville/Morgantown areas: 52160 National Rd. East, St. Clairsville, OH 43950, (740) 695-7902 or (888)
847-7902, TDD (740) 695-7919 or (800) 622-3925, email: [email protected]. Nurse on Call and Utilization
Review Staff – 24 hrs a day/seven days a week: (740) 695-3585 or (800) 624-6961. Massillon area: P.O. Box
4816, Massillon, OH 44648, (330) 837-6880 or (800) 426-9013, TDD (877) 236-2291, email: [email protected].
Nurse on Call and Utilization Review Staff – 24 hrs a day/seven days a week: (330) 837-6880 or (800) 426-9013.
Our hours are Monday - Friday, 8:30 a.m. - 5:00 p.m.
42. Services performed after your physician has advised the Insured that further services are not
medically appropriate or not covered services.
43. Homeopathic treatments.