SSMC Employee Health Benefit Plan
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18. Diabetic Supplies, Equipment and Education
a. Supplies and Equipment. Benefits are available for the following diabetic Supplies and equipment
when ordered or recommended by a Physician and found Medically Necessary according to Plan
provisions:
1) Blood glucose monitors (standard) and blood glucose monitors for the legally blind;
2) Test strips for glucose monitors, visual reading and urine testing;
3) Injection aids;
4) Cartridges for the legally blind;
5) Data management systems;
6) Insulin pumps or insulin infusion pumps when Medically Necessary and when conventional
injection therapy is found inadequate to treat the patient's condition;
7) Insulin and insulin syringes.
Items such as alcohol, swabs, adhesive tape, and gauze are not covered under this benefit. If Covered
Person is eligible for Prescription Drug Expense Benefits shown later in this section, insulin, syringes
and other diabetic Supplies covered under the Prescription Drug Expense Benefits will be paid under
that benefit, not Medical Expense Benefits.
b. Self-Management and Education. Coverage for self-management education services is provided
when the patient is initially diagnosed with diabetes, or when the Physician certifies a significant
change in the patient's symptoms or condition requires changes in the patient's self-management.
These educational services are limited to the following services given to the patient (or on behalf of the
patient such as to a parent for young Dependent children) by:
1) A Physician or his/her staff during an office visit for diabetes diagnosis or treatment. When the
self-management education is provided during an office visit, the one benefit payment for the
office visit will include payment for the self-management educatio n;
2) A certified diabetes nurse educator, certified nutritionist or a certified registered dietician when
referred by a Physician. This education must be provided in a group setting. If it is found that
group education is not available in your area, the Plan may cover individual education;
3) A professional Provider as described above will be covered for services given in the patient's
home. However, it must be decided to be Medically Necessary for the patient to receive services at
home.
19. Aminoacidopathies. Limited coverage is available for certain nutritional supplements (formulas) when
found Medically Necessary and administered under the direction of a Physician for the therapeutic
treatment of the following Aminoacidopathies (disorders that prevent the body from properly digesting
amino acids): phenylketonuria (PKU), branched-chain ketonuria, galactosemia and homocystinuria.
If the Covered Person is eligible for Prescription Drug Expense Benefits shown later in this section,
Aminoacidopthies formulas covered under the Prescription Drug Expense Benefits will be paid under that
benefit, not Medical Expense Benefits.
20. Prosthetics/Orthotics/Braces. Benefits are available for the purchase, or repairs, of Prosthetic devices or
appliances that replace physical organs or parts, or aid in their function. Orthotics, casts or braces needed
to support or align movable parts of the body, or to prevent or correct deformities are covered. The
replacement of devices will be considered for coverage only when needed due to change in the patient's
body condition. Otherwise, the replacement or repairs of braces, casts, trusses, Orthotics, orthopedic
devices are not covered. The Plan excludes devices for athletic use, biomechanical Prosthetics or foot
Orthotics/ devices used for routine foot care. See Foot Care and Podiatry Services shown previously in
this section for limited foot appliance coverage.
