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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.