Medical/Surgical Care ........................................................................................................................................................44
Foot Appliances ....................................................................................................................................................................44
Spinal Manipulation/Chiropractic Services.......................................................................................................................44
Outpatient Mental Illness Care .............................................................................................................................................45
Bereavement Counseling .........................................................................................................................................................45
Diagnostic Tests .........................................................................................................................................................................45
Radiation Therapy ....................................................................................................................................................................45
Chemotherapy ............................................................................................................................................................................45
Rehabilitation Therapy............................................................................................................................................................46
Physical Therapy..................................................................................................................................................................46
Speech Therapy ....................................................................................................................................................................46
Inhalation Therapy ..............................................................................................................................................................46
Occupational Therapy ........................................................................................................................................................46
Kidney Dialysis...........................................................................................................................................................................47
Durable Medical Equipment (DME)....................................................................................................................................47
Ambulance...................................................................................................................................................................................47
Diabetic Supplies, Equipment and Education ...................................................................................................................48
Aminoacidopathies....................................................................................................................................................................48
Prosthetics/Orthotics/Braces..................................................................................................................................................48
Medical Supplies (Home Use) ................................................................................................................................................49
Blood Transfusions ...................................................................................................................................................................49
Contact Lens/Glasses................................................................................................................................................................49
Hearing Aids ...............................................................................................................................................................................49
Oxygen and its Administration..............................................................................................................................................49
Professional Nursing.................................................................................................................................................................50
Private Duty Nursing ..........................................................................................................................................................50
Visiting Nurses......................................................................................................................................................................50
Acupuncture ...............................................................................................................................................................................50
Sleep Apnea Studies..................................................................................................................................................................50
Weight Control Program..............................................................................................................................................................50
Miscellaneous Provisions ..............................................................................................................................................................50
Voluntary or Elective Reproductive Sterilization ............................................................................................................50
Transplants/Autologous Bone Marrow/Stem Cell ...........................................................................................................51
Genetic Counseling and Testing ............................................................................................................................................52
Temporomandibular Joint Dysfunction Syndrome (TMJ)...........................................................................................52
Dental Care .................................................................................................................................................................................52
Prescription Drug Expense Benefits ..........................................................................................................................................52
Covered Prescription Drug Expenses..................................................................................................................................52
Preauthorization Requirements ............................................................................................................................................53
Voluntary Generic Drug Substitution Program ...............................................................................................................53
When Another Plan is Primary.............................................................................................................................................54
Participating Pharmacy...........................................................................................................................................................54
Network Copayments..........................................................................................................................................................54
Plan Identification Card.....................................................................................................................................................54
Obtaining Network Benefits..............................................................................................................................................54
Nonparticipating Pharmacy (Out-of-Network) ................................................................................................................54
Mail Service for Maintenance Drugs...................................................................................................................................55
Mail Order Copayment......................................................................................................................................................55
How to Use the Mail Service Pharmacy Program.......................................................................................................55
Prescription Drug Expense Exclusions................................................................................................................................55
SECTION V - PLAN EXCLUSIONS .......................................................................................................................................57
SECTION VI- MEDICARE INTEGRATION WITH PLAN BENEFITS .....................................................................65
Medicare Secondary Payer (MSP) Current Rules ................................................................................................................65
Effects of Medicare on Plan Benefits.........................................................................................................................................66
Medicare Payment Integration..............................................................................................................................................66
