SAG-AFTRA Health SPD

Medical Benefits

Medical Benefits (Including Mental Health and Substance Abuse)

MEDICAL BENEFITS AT-A-GLANCE

- PLAN I

Deductible

TIHN –
No Deductible

BlueCard PPO/Beacon Health Options –
$250 per person;
$500 per family

$500 per person;
$1,000 per family

Office Visit Copay

$25

None

Plan Pays

Preventive and wellness – Deductible and Copays waived; 100% of Contract Rate
Office visits – Deductible waived; 100% of Contract Rate
Other services – 90% of Contract Rate

70% of Plan’s Allowance

Your Coinsurance

Preventive, wellness and office visits – None
Other services – 10% of Contract Rate

30% of Plan’s Allowance*

Coinsurance Out-of-pocket Limit

$1,000 per person;
$2,000 per family

$2,500 per person;
$5,000 per family

- PLAN II

Deductible

TIHN –
No Deductible

BlueCard PPO/ Beacon Health Options –
$500 per person;
$1,000 per family

$1,000 per person;
$2,000 per family

Office Visit Copay

$25

None

Plan Pays

Preventive and wellness – Deductible and Copays waived; 100% of Contract Rate
Office visits – Deductible waived; 100% of Contract Rate
Other services – 80% of Contract Rate

60% of Plan’s Allowance

Your Coinsurance

Preventive, wellness and office visits – None
Other services – 20% of Contract Rate

40% of Plan’s Allowance*

Coinsurance Out-of-pocket Limit

$1,200 per person;
$2,400 per family

$3,000 per person;
$6,000 per family

*Additionally, Out-of-network Providers may charge you the difference between their charges and the Plan’s Allowance (balance billing). This amount does not apply toward your Coinsurance limit.

The Plan uses the BlueCard PPO network and The Industry Health Network (TIHN) for all in-network medical benefits, except for mental health and substance abuse care. The Plan uses Beacon Health Options In-network Providers for mental health and substance abuse care. Out-of-network services are also covered under these benefits.

Annual Medical Deductible

Services covered under the medical benefits are subject to an annual Deductible based on the calendar year. The medical Deductible is separate from the Deductibles for other benefits provided by the Plan, such as the Hospital, prescription drug and dental Deductibles.

As outlined in the table above, the amount of the medical Deductible varies depending on whether or not you use In-network Providers, and whether you are covered under Plan I or Plan II.

The family Deductible is satisfied when two or more family members have combined to pay the amount of the family Deductible in Covered Expenses in a calendar year. However, the Plan will not apply more than the individual Deductible amount to any one family member. Refer to this example.

The Plan applies Covered 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 received out-of-order with regard to the date of service, particularly when multiple Providers are used.

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 Limits

Once you have satisfied the annual Deductible, the Plan will provide reimbursement of Covered Expenses as shown in the table above. You are responsible for the applicable Copays and Coinsurance.

The Coinsurance out-of-pocket limit is the maximum amount you will have to pay for Covered Expenses during the calendar year after your Deductible and Copays are satisfied. For example, a Plan II Participant who is single and who has satisfied his or her Deductible and applicable Copays is responsible for 20% of the first $6,000 of covered in-network medical expenses, or $1,200 as Coinsurance.

When you have paid your Deductible, applicable Copays and the maximum Coinsurance amount, the Plan will pay 100% of Covered Expenses, with the exception of in-network office visit Copays. Your total in-network out-of-pocket expenses are also limited by the Comprehensive Out-of-pocket Maximum.

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

Medical Benefits

The Plan’s medical benefits provide coverage for medical and surgical treatment as well as mental health and substance abuse treatment. Like medical and surgical treatment, mental health and substance abuse treatment is covered for a vast number of conditions. Among them are anxiety, stress, eating disorders, depression, bipolar disorders, psychosis, schizophrenia and substance abuse (alcohol and/or other drugs). If you have a question about a particular condition and whether coverage is provided:

  • For medical or surgical treatment, contact the Plan at (800) 777-4013.
  • For mental health or substance abuse treatment, contact Beacon Health Options at (866) 277-5383 or www.achievesolutions.net/sag-aftra

The Plan’s medical benefits include coverage for the following:

  • 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. 
  • Therapy exams, that is, one initial medical exam per type of therapy for the Physician or covered therapist who is providing covered therapy treatment. For physical therapy and physical medicine, the Plan will also consider charges
    for an additional exam. Charges from In-network Providers are not subject to the Deductible or Coinsurance; they are subject to the office visit Copay.
  • Urgent care centers.

  • Visiting nurse services when pre-authorized (limited to reasonable and customary both by amount and frequency of visits). Each visit counts as one hour toward the 672-hour limit.
  • 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.

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

If an in-network Physician refers you to an out-of-network radiology, anesthesiology or pathology (RAP) Provider, the Plan will pay the In-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 receives a RAP Claim, it is not always clear that you were referred by an in-network Physician. You must let the Plan know about the referral so that RAP benefits can be paid at the in-network level.

You will also receive the In-network Level of Benefits (based on the Plan’s Allowance) if you receive RAP services as an inpatient or outpatient at an in-network Hospital or facility, regardless of whether or not you were referred by an in-network Physician.

Surgical Benefits

Contact the Plan before undergoing any surgical procedure to determine if the procedure is covered under the Plan, if pre-authorization is required, or to learn of any Plan limitations.

Obtaining a Second Opinion

The Plan encourages you to obtain a second opinion when surgery is recommended. A second opinion can help you determine whether surgery is truly required, or whether some alternative treatment may also be appropriate. The Plan will pay 100% of the Allowance for a second (or third) opinion for you or your Dependent when obtained prior to undergoing a covered surgery. The Deductible and Copay/Coinsurance amount will not apply to the second (or third) opinion.

Important Note About Anesthesia Services

When an In-network Provider performs a colonoscopy that is covered under the Plan’s preventive benefits, anesthesia provided by a separate anesthesiologist will be covered when determined to be medically appropriate by the attending Provider. Under current guidelines, preventive colonoscopies are covered only for adults age 50 or older once every 10 years. For diagnostic or therapeutic colonoscopies and upper gastrointestinal endoscopies, a separate anesthesiologist’s charges will not be covered unless the Plan’s medical consultants determine that it is Medically Necessary. For example, conditions such as pregnancy, extremes of age, or patients with anatomical difficulties that might interfere with airway support would qualify as Medically Necessary for the presence of a separate anesthesiologist. This rule also applies when an Out-of-network Provider performs a preventive colonoscopy. 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. When anesthesia is provided by your surgeon, the fee for this service is part of the surgical package and is not covered by the Plan if charged separately.

Transplants

With the exception of corneal transplants, expenses incurred in connection with organ transplants will not be covered by the Plan unless a written preauthorization 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 in-network facilities. To obtain pre-authorization for a transplant, follow the instructions under “Pre-Authorization for Surgery.”

If your transplant surgery is approved by the Plan, donor expenses are considered for payment, provided that 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.

If you are donating an organ to another person, the Plan does not consider your donor expenses for coverage, because it is not considered Medically Necessary for you.

If you or your Dependents are covered under more than one health plan, including benefits provided by other entertainment industry plans, you should obtain pre-authorization from all plans that provide coverage.

Bariatric Surgery

Charges incurred in connection with bariatric surgery will be considered for payment if you obtain pre-authorization 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.

Please contact the Plan for specific and detailed guidelines regarding benefits for bariatric surgery. To obtain pre-authorization for a bariatric surgery, follow the instructions under “Pre-Authorization for Surgery” below.

Gender Reassignment Surgery

Charges incurred in connection with gender reassignment surgery will be considered for payment if you receive pre-authorization and you meet the criteria adopted by the Plan for such surgeries. Not all charges are eligible. For example, services that are considered cosmetic, such as those listed below, are generally not covered.

Additional examples of non-covered charges include, but are not limited to:

  • Breast augmentation;
  • Brow lift;
  • Calf implants;
  • Chondroplasty (thyroid cartilage reduction);
  • Facial bone reconstruction or facial implants;
  • Gluteal augmentation;
  • Jaw reduction;
  • Lip reduction/enhancement; and
  • Pectoral implants.

To obtain pre-authorization for a gender reassignment surgery, follow the instructions under “Pre-Authorization for Surgery” below. Please contact the Plan for specific and detailed current guidelines regarding benefits for treatment of gender dysphoria.

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, or for certain reconstructive surgery after a mastectomy.

If your Physician advises you that surgery is required for functional reasons, it is strongly recommended that you obtain pre-authorization before having the surgery. That way you will know whether the surgery is covered.

The final amount payable will not be determined until the operative report is reviewed with your Claim. In all cases, your Physician will be asked to furnish certain information to the Plan.

The following is a list of some of the Cosmetic Surgeries and procedures that are NOT covered by the Plan.

  • Abdominoplasty.
  • Alopecia senilis, or male pattern baldness treatment.
  • Blepharoplasty (eyelid surgery) – Elective surgery to the upper eyelids is generally not covered. However, under certain circumstances, the Plan’s medical consultants may review your case to determine if it meets the criteria for coverage. Have your Physician follow the surgery pre-authorization procedures outlined on this page 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 Food and Drug Administration (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 coverage. Have your Physician follow the surgery pre-authorization procedures outlined on this page. The Physician should be certain to include the patient’s height, weight and the number of grams of tissue to be removed from each breast.
  • Chemical peels, 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 that do not require treatment, such as the removal of freckles, age spots, wrinkles, skin tags, etc.
  • Genioplasty (chin implants).
  • Gynecomastia surgery for enlarged male mammary glands, except for documented hormone imbalances, or the presence of tumors or an endocrine producing tumor in the breast.
  • Hair transplants.
  • Laser hair removal.
  • Laser resurfacing.
  • Lipectomy.
  • Liposuction.
  • Otoplasty (ear procedure).
  • 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 above for information on breast implant removal.
  • Rhinoplasty (nose procedure).
  • Rhytidectomy (face lift).
  • Telangiectasia (spider veins) treatment.

Pre-Authorization for Surgery

Transplants, bariatric surgery, gender reassignment surgery and eyelid, nasal and certain breast surgeries have mandatory pre-authorization requirements. Breast surgeries for which coverage is required by the Women’s Health and Cancer Rights Act of 1998 do not require pre-authorization. See more information on these surgeries.

To obtain pre-authorization for a surgery that requires it, the following steps must be taken.

  1. You must advise your Physician of the Plan’s pre-authorization requirement. Your Physician is required to contact the Plan and provide all of the necessary information.
  2. Your surgeon must submit a letter stating the surgical procedures to be performed, the Medical Necessity for the surgery and the anticipated fee. The Physician’s request for pre-authorization must be sent to the Plan and include the patient’s history and physical report, along 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 as to whether the surgery will be covered. The final amount payable will not be determined until the actual operative and pathology reports are received with the Claims and reviewed.

If your surgeon performs different or additional procedures other than those that were pre-authorized, and these procedures are not covered under the Plan, the charges will not be considered for payment.

Surgeon Services

The Plan provides coverage for the surgeon’s fee for covered surgeries. A copy of the operative and pathology reports is 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 Services

If an assistant surgeon is necessary for the procedure, the Plan’s Allowance for the assistant surgeon will be limited to 20% of the Allowed Amount for the surgeon. If a surgical assistant, such as a registered nurse first assistant or Physician assistant, is necessary for the procedure, the Plan’s Allowance for the surgical assistant will be limited to 10% of the Allowed Amount for the surgeon.

Anesthesiologist Services

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:

Benefits for Multiple Surgeries

If multiple surgical procedures are performed at the same time, whether through the same or separate incisions, the Plan will pay benefits based on the following:

  • For the primary procedure, 100% of the Plan’s Allowance.
  • For the second procedure, 50% of the Plan’s Allowance.
  • For each remaining procedure, 25% of the Plan’s Allowance.

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

Use of an Out-of-Network Surgical Suite, Ambulatory Surgical Center or Birthing Center

A surgical suite or an ambulatory surgical center is a site, either in a Physician’s office or an independent facility, where outpatient surgery is performed. If the surgery takes place in an out-of-network surgical suite or ambulatory surgical center, the Plan’s Allowance is limited 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’s Allowance is also limited to $1,000 for the use of an out-of-network birthing center. Coverage for in-network surgical suites and surgical centers and for in-network birthing centers is provided under the Hospital benefits.

Therapy Benefits

Contact the Plan before undergoing any type of therapy to determine if the therapy and related Provider charges are covered, or if there are any limitations or exclusions. All therapy visits must be Medically Necessary for the diagnosis or treatment of an accidental injury, sickness, pregnancy or other medical condition. See complete definition of Medical Necessity.

Medically Necessary therapy for mental health and substance abuse treatment is covered, but it is not subject to the out-of-network allowances or visit limits outlined in this section.

Covered Therapies and Providers

Therapy visits are not considered office visits, so they are subject to the Deductible and Coinsurance. 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, 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 (DC) 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 a registered occupational therapist (OTR).
  • Osteopathic manipulative therapy when performed by a Doctor of Osteopathy (DO).
  • Physical therapy and physical medicine when performed by a registered physical therapist (RPT), or a Physician.
  • Speech/voice therapy when performed by a speech/language pathologist, provided that the services are not part of an educational program.
  • Vision therapy, when performed by a Doctor of Optometry (OD), including developmental vision therapy.

The Plan does not cover fees for health clubs, masseurs, masseuses, fitness instructors, dance therapists, colon hydrotherapists or similar practitioners, even when recommended or prescribed by a Physician. The Plan also does not cover 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 cover 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 receiving the therapy from an In-network or Out-of-network Provider. Additionally, the Plan has a maximum number of visits for certain types of therapy. The table below outlines these Allowances and maximums. The Plan will also consider one initial medical exam per type of therapy for the Physician or therapist who is providing treatment. For physical therapy and physical medicine, the Plan will cover a second medical exam. Additional exams for all types of therapies will only be covered 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.

Medical exams are considered office visits. This means that exams from In-network Providers are not subject to the Deductible and Coinsurance – but they are subject to the office visit Copay.

Plan’s Allowance and Maximums for Therapy Benefits

Acupuncture

Contract Rate

$55 per visit

8 visits*

Biofeedback

Contract Rate

$55 per visit

9 visits

Chiropractic

$45 per visit

$45 per visit

12 visits*

Physical, Occupational and Osteopathic

Contract Rate

$65 per visit

None

Speech and Vision

Contract Rate

$55 per visit

None

*The Plan will not cover 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. As another example, if you used 10 chiropractic visits and then wanted to visit an acupuncturist, no acupuncture visits would be covered since you have already had more than eight therapy visits in the Calendar Quarter.

Preventive and Wellness Benefits

The Plan provides two levels of benefits for routine care: preventive benefits and wellness benefits. Preventive benefits are services identified by the Affordable Care Act (ACA) that must be covered without cost sharing (Deductible, Copays or Coinsurance) when rendered by an In-network Provider. For the most part, the Plan also covers these services at Out-of-network Providers however they are subject to the Deductible and Coinsurance.

Wellness benefits apply to routine care services that are not identified as preventive services by the ACA. Wellness services received from In-network Providers are also covered without cost sharing. Wellness services received from Out-of-network Providers are subject to the Deductible and Coinsurance.

Preventive Benefits

The Plan will cover preventive services whether they are performed separately or in the course of an annual physical. However, to avoid cost sharing at In-network Providers, 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 an Innetwork
Provider for a sore throat, and while there, the Physician recommends you have your cholesterol checked, the visit is subject to the office visit Copay, and the cholesterol test is paid at 100%. Conversely, if you have been diagnosed with a condition such as high cholesterol, and your Physician subsequently 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 as of January 1, 2017 appears in the table below. This list may be updated by the federal government from time to time; for the most current information, visit www.healthcare.gov/coverage/preventive-care-benefits. Many of these services are provided during routine physicals and well-child, well-woman or well-man exams. Routine physicals and well-woman and well-man exams are limited to one per calendar year. Well-child exams are also limited to one per calendar year after age four, 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
  • Screening for:
    • Hearing loss
    • Hemoglobinopathies or 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 Physician’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 six to 12 months at risk for anemia. Iron supplements are covered under the medical benefits and require a Physician’s prescription 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
  • Hepatitis B screening for adolescents at higher risk
  • 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 Physician’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
  • Hepatitis B screening for adults at higher risk
  • Hepatitis C screening for adults at higher risk and one time for everyone born 1945 through 1965
  • HIV screening for everyone ages 15 through 65 and other ages at higher risk
  • Lung cancer screening for 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 for all adults and cessation interventions for tobacco users. Cessation interventions are
    covered under the Optum Quit for Life® Program.

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 Screening 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 higher risk
  • Breast cancer mammography every one to two years for women age 40 or older
  • Cervical cancer screening
  • Chlamydia infection screening for younger women and women at higher risk
  • Contraception – FDA-approved contraception methods, sterilization and contraceptive counseling. Contraceptives that require a Physician’s prescription are covered under the Express Scripts prescription drug benefits. Contraceptives that are  administered in the Physician’s office or that are available over-the-counter are covered under the medical benefits. Over-the-counter items require a Physician’s prescription in order to be considered for coverage. Condoms are not covered.
  • Domestic and interpersonal 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
  • 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 Physician’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, including follow-up testing for women at higher risk
  • Urinary tract or other infection screening

The Plan will not deny coverage for sex-specific benefits for which an individual is otherwise eligible because his or her gender does not align with other aspects of their sex or with the sex assigned to them at birth.

Wellness Benefits

Not all routine services are included in the ACA’s preventive services list. The Plan considers these procedures for coverage under the wellness benefits. The Plan will cover wellness services whether they are performed separately or in the course of an annual physical.

Wellness services received from In-network Providers are not subject to the medical Deductible, Copays or Coinsurance. However, to avoid cost sharing, the primary purpose of your office visit must be for wellness or preventive care. Wellness services provided by Out-of-network Providers are subject to the Deductible 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.
  • Urinalysis.

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. In addition, as outlined here for visiting nurse services, each visit counts as one hour toward the 672 limit.

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 (see below). Because the nursing benefit contains several restrictions, as described below, you must obtain approval before services are rendered. The amount allowed per visit will be determined by the Plan’s Allowable Charge guidelines.

Obtaining Approval for Private Duty Outpatient Nursing Care

The Plan does not cover inpatient private duty nursing services under any circumstances. Private duty nursing care at home may be covered if you obtain advance approval as follows:

  • The nursing services must be prescribed by your Physician 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 (RN), licensed vocational nurse (LVN), licensed practical nurse (LPN) or equivalent state license who is not a relative or resident of your home.
  • The nursing must not be for Custodial Care or long-term care (see Glossary).
  • The Physician 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 your Physician’s report and the 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 Physician prescribes private duty nursing care, please contact the Plan as soon as possible. Also note that services by Christian Science practitioners are not recognized as nursing services by the Plan.

Case Management

Case ManagementOne of the Plan’s most important tools in providing benefits for individuals with a serious 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 the Case Management program. All services and equipment must be pre-authorized by the Case Management team.

The Plan’s Case Management team uses Case Management nurses to assist in approving and arranging necessary services and equipment and with locating appropriate Providers and negotiating rates with Out-of-network Providers when no In-network Providers are available.

Case Management can help with a wide variety of serious illnesses and injuries, including burns, spinal cord injuries, multiple trauma injuries, cancer, cardiovascular disease, stroke, joint replacement postsurgical care, HIV/AIDS, cerebral palsy and multiple sclerosis. The Case Management team can also assist in arranging hospice care for patients with terminal conditions. If you feel that Case Management is appropriate for your care, contact the Plan as soon
as possible.

Case Management services are completely voluntary and are meant to benefit the patient. Accordingly, if the patient and the Physician do not agree that the alternative plan is to the patient’s benefit, the patient is not required to participate in the Case Management program.

The Case Management program is also provided as part of the Plan’s regular health coverage, so there is no additional cost to covered Participants or Dependents.

Non-Covered Medical Expenses

(all practitioners)

The following medical expenses are not covered by the Plan.

  • 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 behavior analysis (ABA).
  • Charitable Hospital care – 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.
  • Cord blood harvesting and storage charges.
  • Cosmetic Surgery and procedures, except where otherwise noted (see above and “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 (dental services are covered under the dental benefit).
  • Durable Medical Equipment, if it is a second or duplicate piece of approved Durable Medical Equipment for travel or convenience purposes.
  • Electrolysis.
  • Environmental equipment, such as air filters, humidifiers and non-allergic bedding.
  • Equipment and procedures not approved by the FDA.
  • Exercise equipment, whirlpools, sunlamps, heating pads and other similar general use items, whether or not prescribed by your Physician.
  • Eyeglasses, contact lenses or eye refractions (except following covered eye surgery or as provided through VSP).
  • Food supplements, herbs, minerals, vitamins and other nutritional supplements.
  • Foot care – Arch supports, heel pads and heel cups. Routine foot care (removal of corns and calluses or cutting of nails) is not covered, except when prescribed by a Physician who is treating you for a metabolic, neurologic or peripheral vascular disease such as diabetes or arteriosclerosis.
  • Gestational surrogate, that is, charges for services rendered to a gestational surrogate or to a fetus implanted into a gestational surrogate.
  • Growth hormones (except when pre-approved by Express Scripts under the prescription drug benefit).
  • Health clubs, Rolfing, Alexander Technique, feldenkrais, bioenergetics, posture realignment, Pilates therapy or yoga.
  • Homeopathic remedies.
  • Hypnosis or hypnotherapy.
  • Infertility treatment, including: infertility services after voluntary sterilization; artificial insemination; assisted reproductive technology (ART) procedures; services, prescription drugs and supplies related to ART procedures; infertility-related non-surgical and surgical procedures; the diagnostic testing performed after the start of infertility treatment; the cost of donor sperm and associated fees; and the cost of donor eggs and associated fees.
  • Inpatient private duty nursing.
  • Intraoperative neurophysiologic monitoring, except in limited cases where the Plan’s consultant determines that it is Medically Necessary.
  • Learning disabilities support or care, specifically, charges in connection with learning disabilities and academic accommodations.
  • Masseur or masseuse services, including services provided by massage therapists (MT), oriental medical doctors (OMD or DOM, 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.
  • Medically unnecessary services or supplies, that is, services or supplies which are 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 refractive errors. The 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 of Dependent children including delivery, post-natal care or elective termination of pregnancy (prenatal care from an In-network Provider and treatment of complications of pregnancy are covered).
  • Psychological testing.
  • Reversal of vasectomy or tubal ligation.
  • Specialty beds such as Sleep Number beds.
  • 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.

For additional information, refer to the general exclusions.