SSMC Employee Health Benefit Plan
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Examples of covered devices or appliances are braces, cervical collars, Jobst garments, splints, traction,
artificial arms, legs, and eyes used to replace or to support functioning parts of the body, penile Prosthetic
implants due to organic caused impotency, breast implants due to covered mastectomies. For example:
coverage includes one wig or hairpiece per Covered Person's Lifetime for hair loss due to non-
Experimental chemotherapy or radiation therapy. No other wigs or hairpiece are covered. (See Section l-
Summary of Benefit for wig/hairpiece benefit limit). For example: this benefit does not include
communication devices, computers, eyeglasses, contact lenses (except Contact Lens/Glasses described
later in this section), Cosmetic devices, dentures or other devices used in connection with teeth, or devices
otherwise excluded under the Plan.
21. Medical Supplies (Home Use). Benefits are available for certain medical Supplies used in the home by
you or your Dependents when ordered by the attending Physician and found Medically Necessary. Items
such as gauze pads, swabs, alcohol, deodorizers, and adhesive tape are not covered. Coverage is limited to
the following items:
a. Ostomy bags and Supplies required for their use.
b. Catheters and Supplies required for their use.
c. Syringes and needles necessary for conditions such as diabetes. Refer to Diabetic Supplies,
Equipment and Education shown previously and Prescription Drug Expense Benefits described later
in this section.
d. Extensive dressings necessary for conditions such as cancer, diabetic ulcers and burns.
e. Sterile surgical dressings following covered Surgery.
22. Blood Transfusions. Benefits are available for blood transfusions, including the cost of blood, blood
products, and blood processing when found Medically Necessary. Coverage is limited to the extent that
the blood, Supplies, or services could not be obtained without cost. Separate charges for storage of blood
or blood products are not covered.
Coverage also includes services related to blood donations, autologous (patient donates own blood) or
directed (donation of blood by individual chosen by patient), when there is a scheduled Surgery that
customarily requires blood transfusions. Coverage includes Services or Supplies for obtaining and
processing the blood only to the extent that such Services or Supplies could not be obtained without cost.
Benefits are not payable for separate charges billed for autologous or directed blood, or blood products, or
for the storage of autologous or directed blood.
23. Contact Lens/Glasses. Benefits are available for the initial contact lens(es) and related exam when
ordered by a Physician following intra-ocular Surgery. The lens(es) must replace the function of the human
lens(es) and be medically required due to intra-ocular Surgery or cataract Surgery. Coverage also covers
the initial pair of eyeglasses and related eye exam needed because of Accidental Injury or disease. Glasses
for correction of refraction are not covered. No other eyeglasses, contact lenses, visual aids or related
exams are covered under this benefit.
24. Hearing Aids. The initial hearing aid and related exams are covered for loss of hearing that occurs while
covered under the Plan and is caused by Accidental Injury or disease or by a covered surgical procedure
rendered while the person was covered under the Plan. The replacement of a hearing aid is not covered,
whatever the reason. No other hearing aids or related exams will be paid.
25. Oxygen and its Administration. Benefits are available for oxygen and the needed Supplies for its
administration when ordered by an attending Physician and found Medically Necessary and appropriate for
self-care home use. Oxygen must be found Medically Necessary, according to Plan limitations, for use in
the treatment of severe hypoxemia (low oxygen levels in the blood) caused by chronic pulmonary
conditions. For example: Chronic obstructive pulmonary disease, pulmonary fibrosis, congestive heart
disease, pulmonary hypertension, and cystic fibrosis.
