SSMC Employee Health Benefit Plan
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the extent such charges are not reimbursed by the donor's plan. Then, this Plan will consider the
Donor's expenses under the recipient's claim. If you or your Dependent act as a donor, the donor
expenses will not be Covered unless the person receiving the organ is Covered under the Plan. Then,
donor expenses will be considered as part of the organ recipient's claim. Donor charges and donor
search charges will be deemed to be Incurred on the date of the transplant even if the services were
rendered before such dates.
c. Autologous Bone Marrow/Stem Cell. Courses of treatment involving high dose chemotherapy or
radiotherapy and autologous bone marrow, stem cell rescue or other hematopoietic support procedures
are not covered as organ and tissue transplants, except for the following (and only then for candidates
who meet established national health and age standards): acute leukemia in remission, resistant non-
Hodgkin's lymphoma, Hodgkin's disease and neuroblastoma as allowed under CMS guidelines. If
CMS guidelines change adding or deleting coverage under Medicare, then this Plan will include or
exclude those procedures. Coverage includes donor expenses the same as donors for organ transplants
shown above.
4. Genetic Counseling and Testing. Benefits are available for genetic tests and counseling only for genetic
disorders that are documented with immediate family history of the disorder. Coverage includes
amniocentesis rendered during Pregnancy based on immediate family history of the genetic disorder and
age of the expectant mother.
5. Temporomandibular Joint Dysfunction Syndrome (TMJ) . Benefits are available for surgical
correction of TMJ or similar disorders the same as any other Illness. However, therapeutic treatment or
therapy in conjunction with TMJ is limited to six visits per each Covered Person's Lifetime. TMJ
appliances are excluded. These limits apply to TMJ or similar conditions. Other conditions of the
temporomandibular joint such as fractures, arthritis, cancer will be considered the same as any other Illness.
6. Dental Care. Medical Expense Benefits are available for you or your Dependents for limited dental care.
Services or Supplies must be given and billed by a Physician or Dentist. Also, refer to Section V - Plan
Exclusions. Coverage is limited to the following dental or medical care:
a. The diagnosis and treatment of oral tumors, cysts, and cancer, cleft palate, tongue Surgery and other
disorders considered medical rather than dental and that would otherwise have been covered if done by
medical Doctors.
b. Injury to Sound Natural Teeth or to the jaw due to an Accidental Injury that was not caused, directly or
indirectly, by biting or chewing. This coverage is limited to care that is Incurred within 90 days from
the date of the accident. Coverage includes restoration of damaged teeth or replacement (dentures or
fixed bridgework) of Sound Natural Teeth lost due to such Injury. In no event will Medical Expense
Benefits be available for the costs to replace or repair damaged crowns, false teeth, orthodontic braces
or any other dental devices.
c. Extraction of impacted teeth.
d. Cutting procedures on the gums (unrelated to extraction of teeth) due to disease or Injury.
H. Prescription Drug Expense Benefits
You and your Dependents may purchase drugs from any Pharmacy. However, if this Plan is considered the
primary payer and you or your Dependents choose an EHS Network Pharmacy or use the Mail Service for
maintenance drugs, you save costs for yourself and your employer.
1. Covered Prescription Drug Expenses. The maximum quantity of each Covered drug purchased at one
time will be limited to a 34-day supply or 100 dosage unit, whichever is greater. Mail service drugs will
be limited to a maximum quantity of a 90-day supply. Prescription refills will be paid for up to one (1)
year from the date of the original prescription. Unless otherwise shown, all drugs must be ordered by the
