The Plan will pay the benefits described in this section on behalf of Covered Persons, provided the benefits are Medically Necessary and not excluded elsewhere in this document. They may be subject to co-payments, deductibles, and/or co-insurance depending on whether the care is provided by an in- or out-of-network provider (See Section 7).

Inpatient Care in a Hospital. The Plan provides coverage for 365 days of care for each Confinement in a Hospital for treatment of medical conditions other than mental health or nervous disorders.

(If your Hospital admission is for treatment of a mental or nervous disorder, the Plan provides coverage for 100 days of care in a Hospital each calendar year. If you are admitted to a mental health Facility instead of a Hospital, please refer to the mental health managed benefit described later in this section.)

A single Hospital confinement means one or more inpatient admissions to a Hospital. When you are admitted to a Hospital after at least 90 days during which you have not been confined in any Hospital, Skilled Nursing Facility or similar Facility, the admission will begin a new period of Confinement. During your hospitalization, the Plan pays Covered Charges for a semi-private Hospital room and for Medically Necessary services and supplies. The services must be provided by an employee of the Hospital. The Hospital must bill for the services and it must retain the money collected for the service.

Some examples of non-covered services include the following:

  • Private duty nurses;
  • Private room, unless Medically Necessary (if not Medically Necessary, you will have to pay the difference between the cost of the private room and the semi-private room);
  • Non-medical items, such as television and telephone;
  • Medications, supplies, and equipment you take home from the hospital; and
  • Custodial care.

Remember to contact the managed benefits coordinator
prior to planned Hospital admissions
or immediately following Emergency admissions.

Inpatient Care in a Skilled Nursing Facility (SNF). The Plan pays for inpatient care in a Skilled Nursing Facility in a semi-private room. It also pays for nursing care, drugs, physical, speech and occupational therapy provided by the SNF, and any service that would be covered if the patient was an inpatient in a

To be considered a Covered Expense, the Confinement in an SNF must be recommended by a physician who certifies that 24-hour skilled nursing care is Medically Necessary as an alternative to hospitalization. Coverage will be provided for a maximum of 180 days in a calendar year. In order to determine whether the care is Medically Necessary, the guidelines used by the Federal Government’s Medicare program will be applied. The Managed Benefits Program Coordinator, in conference with the patient’s Physician, will verify medical necessity and establish when SNF
care is appropriate and eligible for benefits. In addition, to qualify for benefits, you must have been confined to a Hospital for at least three days, and enter the SNF within 14 days following your discharge from a Hospital. No benefits will be paid for care that is determined to be Custodial Care.

Remember to contact the managed benefits coordinator prior to your admission to a Skilled Nursing Facility.

Inpatient Care in a Rehabilitation Facility. The Plan pays for comprehensive physical medicine and rehabilitation (chemical dependence and abuse programs are excluded) for up to 100 days per calendar year for a condition that in the judgment of the managed benefits coordinator can reasonably be expected to result in improvement within a relatively short period of time.
Remember to contact the managed benefits coordinator prior to your admission to a rehabilitation Facility.

Home Health Care. The Plan will provide coverage for up to 180 home health care visits per calendar year if it is provided by a certified Home Health Care Agency possessing a valid certificate of approval
issued pursuant to Article 36 of the Public Health Law. If you receive home health care outside of New York State, a Home Health Care Agency must have Medicare approval as well as an appropriate operating certificate to provide home care issued by the appropriate state agency.

Coverage for home care requires that (a) a home care treatment plan is established and approved in writing by a Professional Provider; (b) the care is provided by a certified or licensed agency; (c) you apply through your Professional Provider to the agency with supporting evidence of your need and eligibility for home care, and (d) the home care is related to the illness or injury for which you have been hospitalized or confined in a Skilled Nursing Facility. This home care must be Medically Necessary at a skilled or acute level of care. Each visit by a member of a
home health care team is considered a separate home health care visit, and four hours of home health aide services are considered as one home health care visit.

Home health care consists of one or more of the following:

  • part-time or intermittent nursing care by or under the supervision of a registered professional nurse;
  • part-time or intermittent home health aide services that consist of primarily rendering direct care to you;
  • physical, occupational or speech therapy if provided by the agency;
  • medical supplies, drugs and medication prescribed by a physician and laboratory services by or on behalf of the agency to the extent such items would have been covered if the person had been confined in a Hospital or Skilled Nursing Facility.

Remember to contact the managed benefits coordinator prior to beginning Home Health Care services.

Hospice Care. The Plan pays for Hospice care during a terminal illness if a person has been certified by their primary care physician as having a life expectancy of six months or less, and if care is provided by a hospice organization that has an operating certificate issued by the New York State Department of Health. If provided in another State, the agency must be approved for hospice services in that State or by Medicare.

The Plan pays Covered Charges for medical care provided by a physician, and bed patient care provided by the hospice organization either in a designated hospice unit or in a regular hospital bed for as long as the care is necessary, as well as day care services provided by the hospice organization, and five days of bereavement counseling services. Home care and outpatient services must be billed through the hospice organization.

Services and care may include intermittent nursing care by nurses or home health aides; physical, speech, occupational and respiratory therapy; social services; nutritional services; laboratory and diagnostic testing; chemotherapy and radiation therapy (for control of symptoms); medical supplies and non-experimental drugs.

Remember to contact the managed benefits coordinator prior to beginning Hospice Care services.

Outpatient Care in a Hospital. Charges for the following outpatient Hospital services are covered in full following the per day deductible explained in Section 7, as long as the patient is physically present; they are for the diagnosis and/or treatment of an illness or injury; they are ordered by a Physician; and they are billed by the Hospital.

  1. Emergency Medical Treatment. Emergency Medical Treatment. The Plan pays for outpatient (or emergency room)
    Hospital charges (excluding physician charges) related to the treatment of an Emergency condition. (See Definition of Emergency Medical Treatment in Section 2.)
  2. Surgery, Chemotherapy and Radiation Therapy. The Plan pays for outpatient hospital charges (excluding Physician charges) related to the performance of a surgical operation, chemotherapy or radiation therapy.
  3. Pre-admission Testing. The Plan pays in full for pre-admission testing in the outpatient department of a Hospital when:
    • a. The testing is ordered by a physician as a planned preliminary to the patient’s admission as a registered bed patient for surgery in the same hospital;
    • b. The testing is necessary for, and consistent with, the diagnosis and treatment of the condition for which the surgery is to be performed.
    • c. The reservations for a hospital bed and an operating room have been made before the tests are performed;
    • The patient is physically present at the hospital for the tests; and
    • The surgery is performed within 7 days of the tests.
  4. Diagnostic X-rays and Laboratory Charges. The Plan pays for outpatient Hospital charges (excluding physician charges) for diagnostic X-ray examination and laboratory tests, including such examinations and tests performed as part of pre-admission testing for a proposed covered hospitalization.
  5. Physical Therapy. The Plan pays for physical therapy treatment performed in the outpatient department of a Hospital and billed by the Hospital, provided that the therapy is in connection with a condition which necessitated hospitalization or surgery; treatment begins within six months from the date of the hospital discharge or surgery; and
    treatment is received within one year of the hospital discharge or surgery.
  6. Hemodialysis Treatment. The Plan pays for hemodialysis treatment performed in the
    outpatient department of a Hospital and billed by the Hospital.

Ambulance Service and Pre-Hospital Emergency Services. The Plan provides coverage for prehospital emergency services (as defined in Sec. 2) and ambulance services so long as such services are provided by an ambulance service certified under the New York State Public Health Law. We will also provide coverage for land ambulance transportation to a Hospital by such an ambulance service in cases where a prudent layperson, possessing an average knowledge of medicine and health could reasonably expect the absence of such transportation to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy, (b) serious impairment to such person’s bodily functions, (c) serious dysfunction of any bodily organ or part of such person, or (d) serious disfigurement of such person. In addition to the services described above, we will also provide coverage for the following Medically
Necessary services provided by a certified ambulance service:

A. Ground or air ambulance service for an urgent condition. When you have an urgent condition the need for care is less than the need for care in an emergency condition, but the condition requires immediate attention. An urgent condition is one that may become an emergency condition in the absence of treatment.

B. Air ambulance service for an emergency condition, and

C. Transportation between facilities.

Air ambulance transportation requires approval from the case management consultant before you receive the transportation, or the payment may be denied retrospectively because it is not considered Medically Necessary.

The first $50.00 in Covered Expenses will be paid in full by the Plan. The balance of the payment will be subject to deductible and co-insurance requirements. Payment to an ambulance organization for which

the Covered Person has no financial obligation (such as a volunteer ambulance) is limited to $50 per calendar year for each Covered Person.

Second Medical Opinions for Cancer. The Plan pays for a second medical opinion by an appropriate
specialist, including but not limited to a specialist affiliated with a specialty care center for the treatment of
cancer, when there is a positive or negative diagnosis of cancer, a recurrence of cancer, or a recommendation for a course of treatment of cancer. If you are referred to an out-of-network physician for a second opinion, you will not be subject to deductibles or co-insurance.

Routine Screening and Examinations.

  • Breast Cancer (Mammography). The Plan pays for annual mammography screening for Covered Persons age 40 and older, as well as a single baseline mammogram those persons age 35 to 39 years old. Also covered are screening mammograms at any age for those at risk who have a prior history of breast cancer or a first degree relative with a prior history of breast cancer. The screening may be provided in the outpatient department of a Facility or in a Professional Provider’s office and no deductible or co-insurance will be applied.
  • Cervical Cancer (Pap Smears). The Plan pays for one annual screening for cervical cancer and its precursor states for women who are covered under the Plan. Cervical cytology screening includes pelvic examination, collection and preparation of a pap smear, and laboratory and diagnostic services provided in connection with examining and evaluating the pap smear. Benefits for pap smears will be paid whether the screening is done in- or out-of network.
  • Routine Gynecological Examinations. The Plan pays for up to two primary or preventive obstetrical or gynecological examinations per year for women who are covered by the Plan. The patient will not be subject to deductible or co-insurance for these examinations, even if they are performed by an out-of-network provider. (Office co-payments, however, will apply.)
  • Osteoporosis (Bone Mineral Density Measurement and Testing).The Plan pays for bone mineral density testing, as well as drugs and devices to treat the osteoporosis. To qua lify for this benefit, the person must meet either the eligibility criteria under the Medicare program or those set by the National Institute for Health (NIH) for the detection of osteoporosis. The law provides that individuals qualifying for coverage shall, at a minimum, include individuals having any of the
    following conditions:
    A previous diagnosis of or a family history of osteoporosis; or
    Symptoms or conditions indicative of the presence or significant risk of osteoporosis; or
    A prescribed drug regimen posing a significant risk of osteoporosis; or
    Lifestyle factors posing a significant risk of osteoporosis; or
    Age, gender, and/or physiological characteristics which pose a significant risk of osteoporosis.
  • Prostate Cancer (PSA Testing). The Plan pays in-network benefits for annual screening for prostate cancer for. A standard diagnostic exam (screening) includes, but is not limited to, a digital rectal exam and prostate-specific antigen (PSA) test. Prostate cancer screening asymptomatic men age 50 and older as part of the Adult Wellness Benefit. Benefits for an annual screening are also provided to men age 40 and over who have a family history of prostate cancer, or at any age for men with a previous history of prostate cancer or other prostate cancer risk
    factors performed as part of routine physical exams is paid in-network only. There is no benefit payable to an out-of-network provider.
  • Colon Cancer (Colonoscopy). The Plan pays (in-network only) for one routine colon cancer screening (colonoscopy) per Covered Person age 50 or older every five years, or when the only reason given for the procedure is “family history.” For purposes of this section, “family” is defined as mother, father, child, brother, sister, aunt, uncle, or grandparent. Colonoscopies are only paid by the Plan when you go to an in-network provider. There is no benefit payable to an out-ofnetwork provider.

Adult Wellness Benefits. In addition to the benefits described above, the Plan pays for adult well care exams and immunizations consistent with the clinical standards of the American Academy of Family Physicians (including shingles vaccine where appropriate). Routine annual physical exams are paid as an in-network benefit only for Employees, Retirees, and their spouses age 19 and older, subject to $15 patient co-pay. The exam may include urinalysis, hematocrit and hemoglobin, lipid panel, occult blood, PSA testing, and electrocardiograpy. If you are over 40 and have a prior or family history of colon cancer, your physician may order sigmoidoscopy and it will be paid as an in-network adult wellness benefit (up to one exam each calendar year.

Well Child Care.The Plan pays for well child visits and childhood immunizations in accordance with the prevailing standards of the Advisory Committee on Immunization Practices (ACIP), and as required by the
New York State Insurance Department. No deductible or co-insurance obligations will be required if you go to an out-of-network provider. However, you may be responsible to pay any amount over the Usual and Customary charges of the provider.

Services covered as part of a well child visit include taking complete medical histories; performing a complete physical exam; performing developmental assessments; providing anticipatory guidance; performing laboratory tests; giving appropriate immunizations; and/or providing other services ordered at the time of the well child visit. The Plan pays for periodic visits to a pediatrician for children up to age 19, in accordance with the visitation schedule established by the American Academy of Pediatrics as adopted by the New York State Insurance Department. From birth to age 2, the Plan pays for eight office visits to a provider. From ages 2 through 5, the Plan pays for annual examinations, and from ages 6 through 18, the Plan pays for a routine examination once every two years.

Maternity Care. The Plan pays for inpatient Hospital or hospital-alternative care for the mother and infant for at least 48 hours following a normal delivery and at least 96 hours following a caesarian
delivery, regardless of whether such care is Medically Necessary. In the event the mother elects to leave the Facility before the end of the minimum stay, the Plan will pay for one home care visit at the mother’s request. This visit does not count toward the home care limit explained elsewhere in this document, and will not be subject to a deductible or co-payment.

Care provided to a maternity patient in a Facility includes parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn clinical assessments. The Plan also provides coverage for complications of pregnancy and for anesthesia during delivery.

“Complications of pregnancy” are conditions that require Hospital admission (not including terminations of pregnancy). The diagnosis must be one that is distinct from pregnancy but which is adversely affected by pregnancy or caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity. Non-elective caesarian section, termination due to ectopic pregnancy, or early spontaneous termination of pregnancy are also considered “complications of pregnancy.”

The following conditions would not be considered “complications of pregnancy”: false labor; occasional spotting; physician-prescribed rest during pregnancy; morning sickness; pernicious vomiting of pregnancy; toxemia; and similar conditions associated with the management of a difficult pregnancy.

The Plan pays Professional Provider charges for maternity care beginning with the first visit in which pregnancy is determined. It includes all prenatal and postpartum care, including services of a licensed midwife, practicing in a collaborative relationship with (a) a licensed physician who is board-certified as an obstetrician-gynecologist by a national certifying body, or (b) a licensed physician who practices obstetrics and has obstetrical privileges at a general hospital licensed under Article 28 of the Public Health Law, or (c) a hospital licensed under Article 28 of the Public Health Law that provides obstetrics through a licensed physician having obstetrical privileges at
such institution, that provide for consultation, collaborative management and referral to address the health status and risks of his or her patients and that include plans for emergency medical gynecological and/or obstetrical coverage.

Sleep Disorder Testing. The Plan pays Covered Charges for diagnostic testing for sleep disorders provided that the Facility where such care is provided is accredited by the Association of Sleep Disorder
Centers (or is in a contractual preceptor relationship with an accredited Facility) and is under the direction and control of a Professional Provider. The Covered Person must be referred by the attending Physician. The need for diagnostic sleep testing must be confirmed by medical evidence, and the Covered Person must have symptoms of either narcolepsy or severe upper airway apnea.

Physician Services for Medical and Surgical Care. The Plan pays for services of a physician for noncosmetic surgical care and medical care and treatment in a Facility, a home, or a physician’s office
providing that the physician who performs the service bills for the service and the services are performed
in connection with a Covered Person’s illness or injury.

When more than one surgical procedure is performed during an operation, the Covered Charge for the
secondary procedure will be paid at not more than 100% of the charge normally paid for the procedure.
The Covered Charge for an assistant surgeon is limited to 20% of the primary surgeon’s Covered Charge
and 20% of the surgeon’s Covered Charge for a physician assistant during surgery. There is no
coverage for incidental procedures.

Podiatry. The Plan pays Covered Charges for services of a Professional Provider for treatment of illness, injury and malformation of the foot.

It does not cover Routine Care of the feet, as defined in Section 2, nor does it cover the following:
examination, diagnosis and treatment of flat feet or any instability or imbalance of the foot, or of any metatarsalgia or bunion (unless an open cutting operation is used); nor does it cover examination, diagnosis and treatment of corns, calluses or toenails, including their cutting or removal, unless the treatment is prescribed by a physician for a metabolic disease, such as diabetes mellitus or a peripheral vascular disease, such as arteriosclerosis, or is necessary surgical intervention for removal of a diseased toenail or treatment of an ingrown toenail requiring an open cutting operation.

Durable Medical Equipment. The Plan pays Covered Charges for rental, repair or maintenance of
durable medical equipment, subject to payment of deductible and co-payment, when such equipment is determined to be Medically Necessary. The Plan may also purchase the equipment, if it determines purchase to be more practical or less expensive than rental. The equipment must be the kind that is generally used for a medical purpose, as opposed to a comfort or convenience purpose. Examples of durable medical equipment include crutches, standard wheelchairs, hospital beds, and home dialysis units. If the equipment is purchased and later sold, the proceeds must be paid to the Plan. The Plan will pay for replacement cost of equipment provided (1) the equipment remains Medically Necessary, with or without a change in the Covered Person’s condition; and (2) the equipment has fulfilled its anticipated life
span as defined by the manufacturer and was subject only to normal wear and tear. Repairs to DME are covered if the DME remains Medically Necessary and as long as the warranty has expired.

The Plan will not pay for deluxe equipment (e.g., motor-driven wheelchairs or beds) if standard equipment is available and medically adequate; items such as air cleaners, air conditioners, dehumidifiers, heating pads and hot water bottles; installation charges or delivery and setup charges; materials purchased to construct equipment; or equipment which is available in a Facility where the patient is confined.

Prosthetics. The Plan pays Covered Charges for prosthetic devices and/or orthopedic appliances used to replace functioning natural parts of the body, and that are determined to be Medically Necessary to relieve or correct a condition caused by an injury or illness. Repairs to and of these devices may also be covered.

A prosthetic device is an artificial organ or body part, including but not limited to artificial limbs
and eyes used to replace functioning natural body parts. Prosthetic devices do not include, for example: eyeglasses, contacts, supportive devices for the feet, hearing aides, medical supplies, certain special articles of clothing or cosmetic devices, dental prosthesis, dentures or other devices used in connection with the teeth. However, the Plan will pay for necessary dental prostheses resulting from an accidental injury to sound natural teeth within 12 months of the accident, for a first pair of corrective lenses after cataract surgery, contacts for treatment of kerataconus and one appliance for mandibular repositioning due to TMJ. Delivery charges, service charges or extended warranties and sales tax are not covered.

Private Duty Nursing Services. The Plan pays Covered Charges for private duty registered nurses, other than a nurse who ordinarily resides in the Covered Person’s home, or who is a member of the Covered Person’s immediate family. Expenses incurred for a private licensed practical nurse will be paid on the same basis as for registered nurses if the attending physician certifies that the nursing care is necessary and a registered nurse is not available. Expenses will not be paid, however, for the first 48 hours of such service provided to the Covered Person in any calendar year. Expenses will also not be paid when the patient is confined to a Facility.

The nursing care must be provided by an R.N., an L.P.N. or L.V.N., all of whom must be state-licensed and registered. The services must be prescribed by a physician and consistent with the condition being treated. The Plan will not pay for private duty nursing rendered by a home health agency, unless the agency is licensed to provide that type of care in the state where it is operating.

Cardiac Rehabilitation. The Plan pays Covered Charges for cardiac rehabilitation programs when
Medically Necessary and prescribed and performed by a Professional Provider. To be eligible for cardiac rehabilitation program, a Covered Person must have had either a documented diagnosis of acute myocardial infarction within the preceding 12 months, coronary bypass surgery, or a diagnosis of stable angina pectoris.

Diabetes Management, Supplies, and Treatment. The Plan pays Covered Charges for the following
equipment and supplies for the treatment of diabetes either as a medical expense or under the Prescription Drug Plan, when they are Medically Necessary and are prescribed by a Professional Provider who is legally authorized to prescribe under Title 8 of the New York Education Law:

Lancelets and automatic lancing devices;
Glucose test strips;
Blood glucose monitors;
Blood glucose monitors for the visually impaired;
Control solutions used in blood glucose monitors;
Diabetes data management systems for management of blood glucose
Urine testing products for glucose and ketones;
Oral anti-diabetic agents used to reduce blood sugar levels;
Alcohol swabs;
Injection aids including drawing up devices or the visually impaired;
Cartridges for the visually impaired;
Disposal insulin cartridges and pen cartridges;
All insulin preparations;
Oral agents for treating hypoglycemia such as glucose tablets and gels
Glucagon for injection to increase blood glucose concentration; and
Insulin pumps and equipment for the use of the pump, including batteries; Insulin infusion
devices; additional Medically Necessary equipment and supplies, as the New York State
Commissioner of Health shall designate by regulation as appropriate for the treatment of
diabetes, and which are available through retail pharmacies, are covered under the Medical
Benefits provision, and cannot be purchased through the retail pharmacy.

The Plan will also pay (as a medical expense benefit) for diabetes self-management programs
provided by a Professional Provider or his staff in connection with Medically Necessary visits
when you have been diagnosed with diabetes, when there has been a significant change in your
symptoms, when you experience the onset of a condition requiring changes in self-management,
or when re-education is Medically Necessary. Education may be provided by a certified diabetes
nurse educator, nutritionist, dietician or other provider as required by law. Education must be
provided in a group setting, wherever possible, unless home visits are determined to be Medically

Also available as medical expense benefits are repair, replacement or adjustment of covered
diabetic equipment and supplies when necessitated by normal wear and tear. Repair and
replacement of diabetic equipment and supplies necessitated because of loss, or damage caused
by misuse or mistreatment are not covered.

Infertility Treatment. Infertility is defined as the inability to achieve a pregnancy according to guidelines and standards adopted by American Society for Reproductive Medicine (ASRM). ASRM defines infertility as the inability to achieve pregnancy after 12 or more months of unprotected intercourse, although earlier
evaluation and treatment may be justified based on medical history and physical findings, and is warranted after six months for women age 35 and over.

By using in-network providers, you minimize your out-of-pocket costs. If you go to a Center of Excellence, you have no out-of-pocket costs. All infertility treatment must be pre-authorized by the Plan’s Managed Benefits Program Coordinator.Covered Services and Supplies: Include, but are not limited to: patient education program orientation; diagnostic testing; ovulation induction/hormonal therapy; artificial/intra-uterine insemination; and surgery to enhance reproduction capability. The Plan’s Managed Benefits Program Coordinator (MBP) will not exclude coverage for Medically Necessary care for the diagnosis and treatment of correctable medical conditions otherwise covered by the Plan solely because the medical condition results in infertility.

Qualified Procedures: Certain procedures, called Qualified Procedures, are covered under the Plan only if you call the Plan’s Managed Benefits Program Coordinator in advance and receive prior authorization. Qualified Procedures are specialized procedures that facilitate a pregnancy but do not treat the cause of the infertility. If the Plan’s Managed Benefits Program Coordinator authorizes benefits, the following Qualified Procedures are covered:

  • A. Assisted Reproductive Technology (ART) Procedures including:
    • In vitro fertilization and embryo placement
    • Gamete Intra-Fallopian Transfer (GIFT)
    • Zygote Intra-Fallopian Transfer (ZIFT)
    • Intracytoplasmic Sperm Injection (ICIS) for the treatment of male factor infertility
    • Assisted hatching
    • Microsurgical sperm aspiration and extraction procedures, including:
      – Microsurgical Epididymal Sperm Aspiration (MESA), and
      -Testicular Sperm Extraction (TESE)
  • B. Sperm, egg and/or inseminated egg procurement and processing and banking of sperm or inseminated eggs. This includes expenses associated with cyropreservation (that is freezing and storage of sperm, eggs or embryos).

Maximum Lifetime Benefit:Benefits paid for Qualified Procedures under the Plan are subject to a lifetime maximum of $25,000.00 per Covered Person. This maximum applies to all covered prescription drugs, hospital, medical and other Covered Expenses that are associated with Qualified Procedures.

Infertility Centers of Excellence:Infertility Centers of Excellence are a select group of participating providers recognized by the Plan as leaders in reproductive medical technology and infertility procedures and contracted by the Plan’s PPO Network. These Centers are available to provide the listed Covered Expense for Services and Supplies as well as Qualified Procedures. If the Managed Benefits Program Coordinator pre-authorizes infertility treatment at Infertility Centers of Excellence, benefits are payable in full. (Qualified Procedures are subject to the
maximum $25,000.00 lifetime benefit.) No co-payments will be applied for services provided at the Centers of Excellence. Co-payments may apply for certain services required by the Center of Excellence and received outside the Center, such as laboratory or pathology tests.

Infertility Exclusions and Limitations: Charges for the following are not Covered Expenses:

  • Experimental infertility procedures.
  • Fertility drugs dispensed in conjunction with Assisted Reproductive Technology (ART) by the Fertility Center or physician are not covered under this benefit. Benefits for infertilityrelated drugs are payable on the same basis as for any other prescription drugs payable under the Plan’s prescription drug benefit as administered by the Pharmacy Benefits Program Manager.
  • Medical expenses or other charges related to genetic selection.
  • Medical expenses or any other charges in connection with surrogacy (of a person not covered under the Plan).
  • Any donor compensation or fees charged in facilitating pregnancy.
  • Any charges for services provided to a donor facilitating pregnancy.
  • Assisted Reproductive Technology services for persons who are clinically deemed to be high risk if pregnancy occurs, or who have no reasonable expectation of becoming pregnant.
  • Psychological evaluations and counseling.
  • Other exclusions and limitations that apply to this benefit are included under Limitations and Exclusions section of the Plan.
  • Any charges for services not pre-authorized as Covered Qualified Procedure Services by the Plan’s Managed Benefits Program Coordinator.

Voluntary Sterilization. The Plan pays Covered Charges for voluntary sterilization, including Professional Provider and Hospital charges. It does not pay for reversal of voluntary sterilization.

Organ or Tissue Transplants. The Plan pays Covered Charges incurred with any organ or tissue transplant listed in this provision, subject to referral and pre-authorization by the Plan’s Managed Care and Utilization Review Coordinator. Transplant coverage is offered under this Plan through a preferred provider network of specialized Professional Providers and Facilities. (Coverage is also provided for transplant services obtained out-of-network at a reduced benefit level.)
As soon as possible, but no longer than ten (10) days after a Covered Person’s attending physician has indicated that the person is a potential candidate for a transplant, the Covered Person or his physician should contact the Plan’s Managed Care and Utilization Review Coordinator for referral to the network’s medical review specialist for evaluation and pre-authorization. A comprehensive treatment plan must be developed for the Plan’s review and must include such information as diagnosis, the nature of the transplant, the setting of the procedure, (name and address of the hospital), any secondary medical complications, a five-year prognosis, two (2) qualified opinions confirming the need for the procedure, as well as a description and the estimated cost of the proposed treatment. The Covered Person may provide a comprehensive treatment plan independent of the preferred provider network, but this will be
subject to medical appropriateness review and may result in out-of-network charges.
Failure to pre-authorize a transplant procedure will mean that the Covered Person will be responsible for payment of a $1,000 deductible charge. For authorization to receive Transplant Services call: (800) 764-3433.

  • Organ Transplant Network: During the pre-authorization review, the Covered Person will be asked to consider obtaining transplant services at a participating transplant center; that is, a Facility that has entered into an agreement with the transplant network provider to provide services to the Plan. This is not an absolute requirement; however, benefits of the transplant and related expenses may vary depending on whether the services are provided in or out of the transplant network.
    If services are provided out-of-network without approval from the Plan’s Managed Care Coordinator, then out-of-network benefits will apply and you will be responsible for Plan deductible, co-payment and co-insurance requirements, plus an additional payment of $1,000.00. If a transplant is performed out-of-network, but the Covered Person has received approval from the Plan’s Managed Care Program Coordinator for the out-of-network services, then the network benefits will apply to the transplant and related expenses.
  • Transplant Benefit Period: Benefits for a covered transplant will accumulate during a Transplant Benefit Period and will be charged towards the transplant benefit period maximums. The term “Transplant Benefit Period” means the period that begins on the date of the initial evaluation and ends on the date that is twelve (12) consecutive months following the date of the transplant. (If the transplant is a Bone Marrow Transplant, then the date the marrow is reinfused is considered the date of the Transplant.)
  • Covered Transplant Expenses: The term “Covered Expenses” with respect to transplants includes the Usual and Customary expenses for the services and supplies that are covered under the Plan (or which are specifically identified as covered only under this provision) and which are Medically Necessary and appropriate to the Transplant. Covered Expenses also include the evaluation, screening and candidacy determination process; charges incurred for organ transplantation; charges for organ procurement, including donor expenses not covered under the donor’s plan of benefits; charges incurred for follow-up care, including immunosuppressant therapy; and charges for transportation to and from the site of the covered organ transplant procedure for the recipient and one other individual, or in the event the recipient or donor is a minor, two (2) other individuals.
    If the transplant procedure is a bone marrow transplant, the Plan will pay for removal of the patient’s bone marrow or for donated marrow. Coverage will also be provided for search charges to identify an unrelated match, treatment and storage of the marrow up to the time of reinfusion. Harvesting of marrow need not be performed within the Transplant Benefit Period. If care is obtained at a Center of Excellence, all reasonable and necessary travel, lodging and meal expenses incurred during the transplant benefit period will be covered up to a maximum of $10,000 per transplant period. Lodging accommodations and meal expenses must be preauthorized by the Plan’s Managed Care Program Coordinator. Re-transplantation will be covered up to two re-transplants, for a total of three transplants
    per person, per lifetime.
  • Accumulation of Expenses: Expenses incurred during any one-transplant period for the recipient and donor will accumulate towards the recipient’s benefit and will be included in the Plan’s overall per person maximum Annual and Lifetime Benefit.

Mental Health and Substance Abuse. The Plan pays Covered Charges for treatment of mental health and substance abuse problems in an appropriate Facility as part of its Managed Benefits Program (see Section 7 for an explanation of the Managed Benefits Program). Utilizing a managed benefits program allows the Plan to provide quality treatment at a higher level of benefits than might otherwise be available to the patient. This provision is intended to encourage the efficient and effective use of mental heath/substance abuse services by providing enhanced benefit levels, or reduced out-of-pocket expenses to the patient through access to a Specialty Preferred Provider Organization (PPO). The benefits provided are limited to charges for services, which are Medically Necessary and appropriate for the care and treatment of the illness. The Managed Mental Health and Substance Abuse PPO Network consists of both local inpatient facilities and outpatient providers. All outpatient providers are licensed mental health professionals. A listing of network providers and facilities is available at

Please note that if you are admitted to a general Hospital as opposed to a mental health Facility for treatment of mental or nervous disorders, your benefits are discussed above in the section entitled “Inpatient Care in a Hospital.”

Mental Health and Substance Abuse Pre-admission Requirements. To receive the Managed Care Benefits provided by this program, you must call the Managed Mental Health and Substance Abuse PPO Network Vendor in the following situations:

  • Elective Inpatient Admission or Partial Hospitalization: You must call at least five (5) working days prior to a scheduled non-emergency, elective inpatient hospitalization. Many psychiatric and most substance abuse admissions are planned and, therefore, require authorization prior to the admission.
  • Emergency Hospital Admission: You must call within two (2) working days after an Emergency hospitalization begins, or as soon as reasonably possible thereafter. Either yourself, a family member, your attending physician, or the Facility can provide notification to the coordinator.
  • Outpatient Care: You must call prior to the fourth (4th) outpatient treatment to pre-certify a continued plan of outpatient treatment.

Failure to call the Managed Mental Health and Substance Abuse Utilization Review Vendor to pre-certify treatment means that the treatment will be processed as an “out-of-network” benefit until such time as a treatment plan is authorized by the Utilization Review Vendor. Retrospective pre-certification of outpatient treatment can only be approved for three outpatient visits. Failure to certify inpatient or outpatient substance abuse will result in the application of greater deductible and a higher patient coinsurance payment. The table on the next page shows the benefits available to you based upon whether you receive care at an in- or out-of-network Facility and whether or not your care is pre-certified as required by the Plan.


Service/Benefit Provision In-Network Out-of-Network
Inpatient Mental Health Care Pre-Certified 100%, up to 100 days per calendar year (no deductible) You pay 50%. The Plan pays 50% of U&C to 30 days per calendar year (after the $500 outof-network hospital deductible).
Inpatient Mental Health Care Not Pre-Certified Out-of-Network applies. You pay 50%. The Plan pays 50% of U&C to 30 days per calendar year (after the $500 outof-network hospital deductible).
Outpatient Mental Health Care Pre-Certified 100%, after $15 per visit co-pay, as indicated. The Plan pays 50% of U&C, after $15 per visit co-pay, up to 30 visits per calendar year (after the $300 out-of-network deductible).
Outpatient Mental Health Care Not Pre-Certified Out-of-Network applies. The Plan pays 50% of U&C, after $15 per visit co-pay, up to 30 visits per calendar year (after the $300 out-of-network deductible).
Outpatient Mental Health Calendar Year Maximum Combined Counts (Network & Out-of-Network ) 100 visits: Pre-Certified only. 30 visits
Lifetime Outpatient Mental Health Maximum Combined Counts (Network & Out-of-Network) Unlimited: Pre-Certified only 60 visits
Inpatient Substance Abuse Pre-Certified 100% of Covered Charges (no deductible). Limit of 4 weeks per period of confinement and 6 weeks per calendar year. 50% of Covered Charges after the $500 out-of-network hospital deductible. Limit of 4 weeks per period of confinement and 6 weeks per calendar year.
Inpatient Substance Abuse Not Pre-Certified 100% of Covered Charges (no deductible). Limit of 4 weeks per period of confinement and 6 weeks per calendar year. 50% of Covered Charges after the $500 out-of-network hospital deductible. Limit of 4 weeks per period of confinement and 6 weeks per calendar year.
Outpatient Substance Abuse 100% of Covered Charges (no deductible). Maximum total of 60 visits per calendar year, including 20 visits for family members. 50% of Covered Charges. Maximum total of 60 visits per calendar year, including 20 visits for family members

Note: Timothy’s Law requires that if a patient is suffering from a “biologically based mental illness” as defined in this document, or is a “child with serious emotional disturbances” as defined in this document, the inpatient mental health benefit will be the same as for any other illness. In addition, if a patient is suffering from a “biologically based mental illness” as defined in this document, or is a “child with serious emotional disturbances” as defined in this document, the outpatient mental health care benefit will be consistent with the benefit payable as an office visit to any other Professional Provider. However, any such claims will be subject at all times to review and/or retrospective denial by the plan’s managed care consultant.

Physical Medicine Services (Chiropractic, Physical and Occupational Therapies).
The Plan has
arranged to provide “in-network” physical medicine benefits when treatment and services are provided through the Optum Health PPO Network and Utilization Review Vendor, a network of licensed providers of chiropractic services, physical therapy and occupational therapy.

Use of in-network providers will enable Covered Persons to receive “in-network benefits” (a per visit copay) for physical medicine services. Please note that physical therapy and occupational therapy services must be prescribed by a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.). In-network providers will work directly with the Optum Heath network to have services reviewed in order to obtain the highest available network.

You may also use out-of-network providers for physical medicine treatments (chiropractic, physical and occupational therapy services) but the Plan’s “out-of-network” coverage will apply. You will be responsible for “out-of-pocket” costs, including the Plan’s calendar year deductible, co-payment and coinsurance and you will be allowed eimbursement only up to the in-network allowance.

To receive the maximum out-of-network benefits available, the patient should contact the Managed Physical Medicine PPO Network Vendor any time that out-of-network physical medicine services will exceed 15 visits in a calendar year. Otherwise, the patient may be subject to a retrospective denial of benefit payment. We recommend notifying the Optum Health PPO Network and Utilization Review Vendor in advance in order to avoid benefit reductions, or denial of claims that are determined not to be Medically Necessary.

  • Pre-Certification Assistance.
    Pre-certification and authorization for Physical Medicine treatment is a contractual responsibility between Optum Health and the network providers.Members being treated by an Optum Health in-network provider do not need to arrange for precertification.Providers participating in the network will arrange for treatment pre-certifications without any requirement from the patient. However, when receiving care from out-of-network providers, the Covered Person is responsible for pre-certification of benefits. Otherwise, you risk that treatment will not be paid for when it is no longer Medically Necessary.

    Failure to pre-certify physical medical treatment may result in a reduced payment by the Plan, increasing the patient’s co-insurance. See the table below for details on charges that are the responsibility of the patient depending on where care is received.


Service/Benefit Provision In-Network Out-of-Network
Chiropractic Services/ Physical and Occupational Therapies/Physical Medicine Services $15 patient co-pay Per office visit (no deductible). $15 patient co-pay, deductible and coinsurance per office visit apply.
Co-Insurance Not Applicable (per visit co-pay only) Pre-Certification Performed.In-Network providers of Physical Medicine PPO will notify the Utilization Review Vendor directly without any requirement from you. (Please always verify that the provider you choose participates in the Physical Medicine PPO network.) The member/patient has no notification responsibility other than to notify the provider of service that their Health Plan participates in the Physical Medicine PPO Network. The Utilization Review Vendor will perform their utilization review, and furnish the treatment precertification directly to the innetwork
provider of service.
First 15 visits in any Calendar Year:
Following the patient co-pay and the calendar year deductible, you pay 20%; the Plan pays 80% of the Optum Health
PPO Network vendor’s allowable charges for in-network PPO services, up to the outof-pocket maximum expenses; then the
Plan pays 100% following the $15 per visit patient co-pay. The co-insurance is the patient’s responsibility, as is the difference between the doctor’s charge and the “innetwork” allowance.

Pre-Certification of Benefits after 15 Visits:
Your out-of-network provider should call the Optum Health Network Provider prior to the 16th visit to avoid retrospective benefit declinations when services are determined not to have been Medically Necessary. After the 15th physical medicine service visit, reimbursement is at 50% of the network allowance following the $15 per visit patient co-pay. The member’s co-insurance of 50%, the patient co-pay and the charges by an outof-network provider that are above the Plan’s “in-network” allowance are entirely the member’s responsibility, and do not apply towards the patient’s out-of-pocket
expense maximum.

Mandatory Second Surgical Opinions. The Plan pays for a mandatory second surgical opinion when you are planning to undergo certain surgical procedures such as those listed below. You must call the Managed Benefits Program (MBP) Coordinator at least 14 days before undergoing these non-emergency, inpatient or outpatient surgeries in order to determine whether a second opinion must be obtained. If you do not call the MBP Coordinator or do not obtain a second opinion when one is required, you may be responsible to pay up to $500.00 toward the cost of the care. If surgery is determined not to be Medically Necessary, surgical benefits may be disallowed altogether.
The Plan will pay 100% of the Usual and Customary (U&C) charges (or 100% of PPO allowances) for a second surgical consultation, subject to the following:

  • Covered Charges for the second opinion surgeon are limited to the examination and consultation.
  • The second opinion must be secured from a Board Certified Specialist in the field for which the patient is contemplating surgery.
  • The second opinion surgeon must not be a part of the same medical or surgical group as the first opinion surgeon.
  • The Employee and the Physician providing the second opinion must complete the appropriate claim forms required by the Plan.

When you call the Managed Benefits Program (MBP) Coordinator, they will determine whether a second opinion is required. In many cases, the MBP Coordinator may waive this requirement. If the second opinion differs from the first opinion, a third opinion may be obtained following all of the guidelines outlined here. Regardless of the recommendation, the decision to have Medically Necessary surgery lies with the patient or patient’s guardian. (A non-mandatory second and third surgical opinion is also a covered benefit.)

The following types of surgery require you to obtain a Mandatory Second Surgical Opinion:

  • Bariatric Surgery
  • Breast Surgery (non-diagnostic) (Note: breast reconstruction surgery after a mastectomy does not require a second opinion.)
  • Heart Surgery (elective or non-emergency)
  • Hysterectomy
  • Intradiscal Electrothermal Annuloplasty (IDET)
  • Joint Replacement Surgery
  • Laminectomy
  • Orthotryspy (Extracorporeal Shock Therapy of Plantar Fascitis)
  • Nasal Surgery Panniculectomy (removal of excess external abdominal adipose tissue), and all other Plastic Surgery (cosmetic or reconstructive)
  • Prostatectomy
  • Spinal Fusion
  • TMJ (Tempro-Mandibular Joint Disorder) Surgery