MAJOR MEDICAL BENEFITS

Major medical benefits are provided to all eligible participants. The Plan uses the following managed care networks for major medical benefits:

Deductible
Major medical charges are subject to a calendar year deductible. This is a separate deductible from the deductibles for any other benefits provided by the Plan, including the hospital deductible. The amount of the major medical deductible varies depending on whether or not you use network providers and the Plan for which you are eligible. Refer to the chart below.

The family deductible is satisfied when at least two or more family members have paid the amount of the family deductible in covered expenses, except that the Plan will not apply more than the individual deductible amount to any one family member. See the example under “Hospital Deductible” on page 28.

The Plan applies expenses toward your deductible as it processes claims, rather than according to the date of service. Providers submit their claims in accordance with their own billing schedules and claims are frequently not received in the order of their date of service, particularly when multiple providers are used.

Major Medical Deductibles

	Network	Non-Network
Plan I	TIHN – $150 per person/$300 per family Blue Cross/PHCS – $250 per person/$500 per family	$500 per person/$1,000 per family
Plan II	TIHN – $150 per person/$300 per family Blue Cross/PHCS – $500 per person/$1,000 per family	$750 per person/$1,500 per family
Lower Cost Self-Pay	TIHN – $150 per person Blue Cross/PHCS – $500 per person	$750 per person

If your eligibility changes from Plan I to Plan II or Lower Cost Self-Pay during a calendar year, any charges that applied toward your deductible under Plan I will apply toward your Plan II or Lower Cost Self-Pay deductible. If your eligibility changes from Plan II or Lower Cost Self-Pay to Plan I during a calendar year, the reverse is also true.

Co-insurance, Co-payments and Out-of-Pocket Maximums

Once you have satisfied the annual deductible, the Plan will provide reimbursement of covered expenses as shown in the
table below.

The out-of-pocket maximum is the maximum amount you will have to pay for covered expenses during the calendar year after your deductible is satisfied. When you have paid your deductible and the maximum out-ofpocket amount, the Plan will pay 100% of covered expenses with the exception of network co-payments.

Major Medical Co-insurance

	Network	Non-Network
	Co-insurance	Co-insurance	Your Out-of-Pocket Maximum
Plan I	100% of network rate with your copayment of: $15 per office visit $15 for surgery performed in a doctor’s office* $100 per inpatient surgery $100 per outpatient surgery** $100 maternity care – global	80% of Plan’s Allowance	$1,000 per person/ $2,000 per family
Plan II	Same as Plan I except there is a $25 copayment per office visit and a $25 copayment for surgery performed in a doctor’s office*	70% of Plan’s Allowance	$1,500 per person/ $3,000 per family
Lower Cost Self-Pay	Same as Plan II	Same as Plan II	$1,500 per person

* If surgery is performed during a scheduled office visit, you are only responsible for one co-payment for that visit.
** This applies to surgery performed in 1) the outpatient department of a hospital, 2) a freestanding surgical center, or 3) a physician’s surgical suite.

If your eligibility changes from Plan I to Plan II or Lower Cost Self-Pay during a calendar year, any charges that applied toward your out-of-pocket maximum under Plan I will apply toward your Plan II or Lower Cost Self-Pay out-of-pocket maximum. If your eligibility changes from Plan II or Lower Cost Self-Pay to Plan I during a calendar year, the reverse is also true.

Major Medical Benefits
The Health Plan covers a wide range of major medical services including the following:

• Ambulance – Professional ambulance service and regularly scheduled airlines or railroads for emergency transportation to or from the nearest legally constituted hospital which has the facilities to treat your medical problem. Services provided to relocate a patient for family or personal convenience are not covered.
• Anesthetics and their administration.
• Artificial limbs and eyes, crutches, splints, casts and braces, surgical dressings, and medical supplies when prescribed by a doctor, including:
  • Initial charge for appliances (does not include dental appliances) to replace or aid the function of physical organs or parts.
  • Initial pair of orthopedic or corrective shoes following surgery.
  • Orthopedic or corrective shoes for children under 12, two pair in a calendar year.
• Birth control – Norplant, IUDs and Depo-Provera (Birth control pills and diaphragms are covered under the Medco
  Prescription Drug Program.).
• Blood and plasma.
• Breast capsulectomy when medically necessary due to pain from contracture. Benefits are payable for a maximum of one surgery per breast per lifetime. This limit does not apply to breast surgeries resulting from cancer treatment. Please see page 39 for surgery pre-authorization requirements.
• Cardiac and cerebrovascular rehabilitative therapy. Benefits are payable for a maximum of three months, if such therapy commences within six months of a clinical cardiac or CVA (cerebrovascular accident) episode.
• Certified nurse practitioner acting within the scope of his or her license.
• Chemotherapy.
• Christian Science practitioner. The Plan does not pay for any medical treatment when you are receiving services from a Christian Science practitioner. The Plan does not pay for Christian Science homes or sanitariums.
• Cosmetic surgery, only if necessary:
  • For the prompt repair of accidental injury; or
  • To repair birth defects (congenital anomalies) as certified by a doctor, on individuals under 19 years of age; or
  • For certain reconstructive surgery following a mastectomy, including reconstruction of the breast on which the mastectomy was performed, surgery on the other breast to produce a symmetrical appearance, and prostheses and physical complications of all stages of mastectomy, including lymphedemas (as required by the Women’s Health and Cancer Rights Act of 1998).
• Dentist’s charges as a result of accidental injury to natural sound teeth when repair work is completed within six months of the accident. A natural sound tooth is one which has not been restored or has been restored with amalgam or composite filling. A natural sound tooth does not include a missing tooth. The Plan may consider the repair of a tooth which was previously crowned provided the accidental injury is due to external causes and resulted in either hospitalization or surgery to the injured tooth.
• Dentist’s charges for the removal of cysts and tumors.
• Dialysis treatment.
• Drugs and medications dispensed by the doctor’s office. The Plan will only consider certain medications, such as environmental antigens.
• Drugs and medications requiring a doctor’s or dentist’s prescription and dispensed by a registered pharmacist for eligible participants who are not covered by the Medco Prescription Drug Program (see page 47). Benefits are payable at the nonnetwork level subject to the major medical deductible.
• Drugs and medications that do not require a prescription if you are under the care of a physician for a current illness. The doctor must state, in writing, to the Plan Office the necessity for the use of such medication for the treatment of your illness. The non-prescription drugs must be generally accepted treatment for a given condition or illness. Not included are non-prescription drug items dispensed in the doctor’s office, food and/or nutritional supplements and homeopathic remedies or vitamins taken orally, or by injection, except as described on page 46.
• Durable medical equipment – Rental or purchase when prescribed by a doctor, such as a wheelchair or hospital bed. Total rental payments are limited to the Plan’s Allowance for the purchase of the equipment, or a similar piece of equipment that will adequately treat the condition. If equipment is to be used for an extended period of time, purchase may be preferred. NOT ALL EQUIPMENT IS COVERED. CHECK WITH THE PLAN OFFICE.
  
  Note: In order for the Plan to consider charges for durable medical equipment, the equipment must meet the criteria outlined in the Glossary under “Durable Medical Equipment” on page 91.
• Eyeglasses (initial pair only), or contact or scleral lenses when required following a covered eye surgery.
• Food allergy testing, when performed as part of the normal work-up of an allergy patient. The tests must be medically necessary. The Plan does not cover allergy treatments such as food antigens.
• Foot orthotics when prescribed by a doctor, subject to the following replacement guidelines:
  • Age 16 or younger – One pair every 12 months.
  • Age 17 or older – One pair every 24 months.
  The Plan does not cover additional pairs of orthotics purchased for different styles of shoes.
• Hearing aids for:
  • Participants and dependents covered under Plan I; and
  • Individuals under age 19 who have congenital hearing defects and are covered under Plan II or the Lower Cost Self-Pay Plan.
  This benefit is payable at the applicable coinsurance level (100%, 80% or 70%) up to a maximum payment of $1,500 per device. Devices are limited to one per ear per three-year period. Repairs and battery replacement are not covered.
• Home health care (may include nursing, durable medical equipment, and other medical supplies such as IV medications). Limitations on durable medical equipment and nursing care are outlined on this page and page 43.
• Lab and diagnostic tests to diagnose an illness or injury. Only tests which are appropriate for the clinical diagnosis as determined by medical consultants for the Plan will be considered. All tests are subject to medical review. Lab tests that are part of a panel will not be paid as separate tests.
• Mammogram (limited to one per year unless diagnosis exists).
• Nutritional counseling by a Registered Dietitian (R.D.) for participants or dependents with chronic illnesses such as diabetes (including gestational diabetes), coronary artery disease, ulcerative colitis, Crohn’s Disease, malabsorption syndrome, cystic fibrosis, HIV/AIDS and cancer. Nutritional counseling is not subject to the major medical deductible and is limited to one initial and two follow-up visits per person per lifetime.
• Obstetrical care and delivery for participants or their spouses or same-sex domestic partners, when rendered by an M.D. or Certified Nurse Midwife, including preand post-natal care and delivery. Maternity care, other than for complications of pregnancy, is not covered for dependent children. Additional charges for diagnostic tests such as ultrasound or amniocentesis may be considered separately, if medically necessary. Obstetrical benefits are not payable prior to delivery. If you change obstetricians and/or midwives during your pregnancy, the Plan will only
  consider charges up to the global maternity allowance.
• Oxygen and its administration.
• Pap test (limited to one per year unless diagnosis exists).
• Pediatrician’s charges for attendance at birth by cesarean section.
• Physician’s services – Fees of a legally qualified licensed physician or surgeon for professional medical or surgical services in or out of the hospital or at an urgent care center.
• Polysomnography (sleep studies) when approved in advance. The Plan Office will need to review the referring physician’s clinical exam notes and a completed sleep study questionnaire, which includes the Epworth Sleepiness Scale.
• Private duty outpatient nursing (R.N., L.V.N., L.P.N. or equivalent state license) other than a relative or resident in your home when approved in advance, see page 43.
• Radiation therapy.
• Radium and radioactive isotope therapy.
• Rast testing – The Plan will consider the minimum number of tests that are medically required in order to make a diagnosis.
• Temporomandibular joint syndrome (TMJ) treatment, only when osseous changes (bony abnormalities) exist and can be determined by x-ray, or in situations in which soft tissue degeneration in the temporomandibular joint can be documented. Dental expenses in connection with orthodontia are not included.
• Therapy benefits, subject to specific limitations. Refer to page 40.
• Therapy exam – One initial medical exam per type of therapy for the doctor or covered therapist who is providing covered therapy treatment.
• Visiting nurse when approved in advance (limited to reasonable and customary both by amount and frequency of visits). Each visit counts as one hour toward the 672 hour maximum as described on page 43.
• Wellness or preventive services, such as physical exams and certain diagnostic tests, subject to specific limitations. Refer to page 42.
• X-rays.

Special Rules for Radiology, Anesthesiology and Pathology (RAP) Providers
If a network physician refers you to a nonnetwork radiology, anesthesiology or pathology (RAP) provider, the Plan will pay the network level of benefits for the RAP claims. Payment will be based on the Plan’s Allowance and you will be responsible for charges over this amount. When the Plan Office receives a RAP claim it is not always clear that you were referred by a network doctor. You must let the Plan Office know about the referral so that RAP benefits can be paid at the network level.

You will also receive network benefits (based on the Plan’s Allowance) if you receive RAP services as an inpatient or outpatient at a network hospital or facility, regardless of whether or not you were referred by a network physician.

Surgical Benefits
Contact the Plan Office before undergoing any surgical procedure to determine if the procedure is covered under the Plan, if a pre-authorization is required and if there are any limitations.

Obtaining a Second Opinion
The Plan encourages you to obtain a second opinion when surgery is recommended. A second opinion assists you in determining whether surgery is required or whether some alternative treatment may also be appropriate. The Plan will pay 100% of the Allowed Amount for a second (or third) opinion for you or your dependent for a covered surgery. The deductible and co-payment/co-insurance amount will not apply to the second (or third) opinion.

Transplants
With the exception of corneal transplants, expenses incurred in connection with organ transplants will not be considered as a covered expense under the Plan unless a written pre-authorization approval is obtained. The Plan reserves the right to deny coverage for a transplant if it is not performed in a facility that is on the list of authorized network facilities. PHCS maintains the list of authorized network facilities outside California and Blue Cross maintains the list of authorized network facilities inside California. Be sure to inform PHCS or Blue Cross of the name of the hospital in which the transplant will take place. To obtain pre-authorization for a transplant, please follow the Pre-Authorization instructions on the next page.

If your transplant surgery is approved by the Plan, donor expenses are considered for payment provided the donor does not have such coverage under his or her own medical insurance plan. Written documentation from the donor’s insurance plan is required. However, if you are donating an organ to another person, the Plan does not consider your donor expense for coverage because it is not considered a medically necessary expense for you.

If you or your dependents are covered under more than one health plan, including Writers, Directors, or AFTRA, we recommend that you obtain pre-authorization from all plans.

Cosmetic Surgery
The Plan does not cover cosmetic surgeries except under specific limited conditions. Eyelid, nasal, and breast surgeries have a mandatory pre-authorization requirement. The Plan will cover cosmetic surgery necessary for the prompt repair of accidental injury, or to repair birth defects of an individual under age 19, or for certain reconstructive surgery following a mastectomy.

If your doctor advises you that surgery is required for functional reasons, it is strongly recommended that you obtain pre-authorization before the surgery is performed. That way you will know whether it is covered. The final amount payable will not be determined until the actual operative report is reviewed. In all cases, your doctor will be asked to furnish certain information to the Plan. If you are required to be examined by an independent medical examiner selected by the Plan, the cost of the examination will be paid by the Plan.

The following is a list of some of the cosmetic surgical procedures NOT covered by the Plan.

• Abdominoplasty.
• Alopecia senilis or male pattern baldness treatment.
• Blepharoplasty (eyelid) – Elective surgery to the upper eyelids is generally not covered, however, under certain circumstances it may be reviewed by the Plan’s medical consultants to determine if it meets the criteria for a covered expense. Please have your physician follow the Surgery Pre-Authorization procedures and provide an ophthalmologist’s report which includes an automated visual field test and pre-operative frontal and lateral gaze photos.
• Botox injections, except for the treatment of certain medical conditions as approved by the FDA.
• Breast reduction – Elective breast reduction is generally not covered, however under certain circumstances it may be reviewed by the Plan’s medical consultants to determine if it meets the criteria for a covered expense. Please have your physician follow the Surgery Pre-Authorization procedures and include the patient’s height, weight and the number of grams of tissue to be removed from each breast.
• Chemical peel.
• Collagen injections, except when used for the restoration, repair and correction of abnormalities or defects caused by an accident or covered surgery.
• Dermabrasion.
• Dermatology procedures for skin conditions which do not require treatment, such as the removal of freckles, age spots, wrinkles, etc.
• Genioplasty (chin implants).
• Gynecomastia surgery for enlarged male mammary glands, except for documented hormone imbalance or presence of tumor in the breast or an endocrine producing tumor.
• Hair transplants.
• Laser hair removal.
• Laser resurfacing.
• Lipectomy.
• Liposuction.
• Otoplasty (ear).
• Panniculectomy.
• Revision of scar tissue from previous cosmetic surgery. See page 35 for information on breast capsulectomies.
• Rhinoplasty (nose).
• Rhytidectomy (face lift).
• Telangiectasia (spider veins) treatment.
• Ventral hernia when done at the same time as abdominoplasty, panniculectomy or lipectomy.

Pre-Authorization for Surgery
Eyelid, nasal and breast surgeries, as well as organ transplants, have a mandatory preauthorization requirement. To obtain preauthorization for surgery, the following steps must be taken.

You must advise your physician of the Plan’s pre-authorization requirement. Your doctor is required to contact the Plan and provide all of the necessary information directly to the Plan Office.

Your surgeon must submit a letter stating the surgical procedures to be performed, the medical necessity for the surgery and the anticipated fee for the surgery. The doctor’s request for pre-authorization must be sent to the Plan Office and must include the patient’s history and physical report, together with pre-operative photographs for eyelid, nasal and breast surgeries. The Plan’s medical consultants will review the information and advise you in writing if the surgery is covered. The final amount payable will not be determined until the actual operative and pathology reports are reviewed. If your doctor performs different or additional procedures than those that were pre-authorized, and these procedures are not covered under the Plan, these charges will not be considered for payment.

Surgeon
The Plan provides coverage for the surgeon’s fee for covered surgeries. A copy of the operative and pathology reports are required for most surgeries. Please have your surgeon include the reports when the surgeon’s charges are submitted. Surgical benefits are payable whether surgery takes place in or out of the hospital.

Assistant Surgeon
The Plan will consider 20% of the amount that is considered for the surgeon if an assistant is necessary for the procedure.

Anesthesiologist
The Plan will consider an allowance that takes into account the type of surgery, time in attendance and area of the country in which the surgery is performed. Please see page 38 for special rules on when network benefits are paid for anesthesiology and other RAP services.

Benefits for More Than One Surgery
If multiple surgical procedures are performed at the same time, whether through the same or separate incisions, the Plan’s Allowance is limited as follows:

• 100% of covered expenses will be allowed for the major procedure;
• 50% of covered expenses for the second procedure; and
• 25% of covered expenses for each remaining procedure.

Procedures that are considered global to, or incidental to another covered procedure are not allowable.

Use of a Non-Network Surgical Suite, Ambulatory Surgical Center or Birthing Center
A surgical suite or an ambulatory surgical center is a site, either in a doctor’s office or an independent facility, where outpatient surgery is performed. If the surgery for you or a dependent takes place in a non-network surgical suite or ambulatory surgical center, the Plan will allow up to $1,000 for use of the suite’s operating and recovery rooms and all central supplies. The Plan will also allow up to $1,000 for the use of a non-network birthing center.

Therapy Benefits
Contact the Plan Office before undergoing any type of therapy to determine if the therapy and provider are covered and if there are any limitations.

Covered Providers
For physical therapy and physical medicine the Plan will recognize only the fees of a Registered Physical Therapist (R.P.T.), Medical Doctor (M.D.), Doctor of Chiropractic (D.C.), or Doctor of Osteopathy (D.O.).

For occupational therapy the Plan recognizes only the fees of an Occupational Therapist, Registered (O.T.R.).

For acupuncture, the Plan recognizes only the fees of a licensed Certified Acupuncturist.

The Plan does not consider the fees of health clubs, masseurs, masseuses, fitness instructors, dance therapists, colon hydrotherapists or similar practitioners, even when recommended or prescribed by a doctor. Nor does it recognize the fees of medical assistant therapists, aides or other providers not specifically licensed by the state to render physical therapy, physical medicine or rehabilitative therapy, even though they are operating under the supervision of a covered provider. The Plan does not consider the fees for rolfing, alexander technique, feldenkrais, bioenergetics, posture realignment, pilates therapy or yoga.

Plan’s Allowance for Therapy Benefits
For non-network providers, the Plan will consider up to $65 per session for services rendered by an R.P.T., M.D., D.O., or O.T.R. For services rendered by a non-network speech or voice therapist, vision therapist, or Certified Acupuncturist, the Plan will consider up to $55 per session. For network providers, these dollar amounts are subject to the contract allowance.

For services rendered by network and nonnetwork chiropractors, the Plan will consider up to $45 per session.

The Plan will also consider one initial medical exam per type of therapy for the doctor or therapist who is providing treatment. For physical therapy and physical medicine, the Plan may consider one medical exam per year in addition to the initial exam. This additional exam will only be considered if there is a significant change to the patient’s condition that warrants a re-examination. This determination will be based on a review of medical records by the Plan’s medical consultants.

The Plan will consider up to 12 outpatient sessions every calendar quarter for any one or combination of the following types of therapy, when prescribed by a doctor:

• Chiropractic (services must be provided by a D.C.) – The Plan’s benefit for chiropractic care is limited to traditional chiropractic services, which include the initial physical examination, subsequent chiropractic manipulations and x-rays of the spine when medically necessary. No benefits will be paid for any other diagnostic tests performed or ordered by a chiropractor even if the provider is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
• Occupational rehabilitation (services must be provided by an O.T.R.).
• Osteopathic manipulative therapy (services must be provided by a D.O.).
• Physical therapy or physical medicine (services must be provided by an R.P.T., M.D., D.C., or D.O.).
• Speech/voice (services must not be part of an educational program).
• Vision.

The Plan will consider up to eight outpatient sessions every calendar quarter for acupuncture when provided by a Certified Acupuncturist. No benefits will be paid for any diagnostic tests performed or ordered by a Certified Acupuncturist even if the provider is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.

The Plan will not consider more than 12 outpatient sessions every calendar quarter for any combination of all the above therapies.

In addition, for biofeedback therapy, the Plan will consider up to $55 per session for up to nine sessions every calendar quarter. However, benefits are payable only if biofeedback is recommended and/or prescribed by a physician for migraine headaches, hypertension, chronic pain, organic muscle abnormalities, chronic anorectal dysfunction associated with incontinence and constipation, or chronic pelvic muscular dysfunction associated with urinary incontinence.

Extended Therapy Benefit
The Plan may consider more than the 12 visits per calendar quarter for physical therapy and/or physical medicine when rendered by an R.P.T., M.D., or D.O. or for occupational therapy when rendered by an O.T.R. The extended therapy benefit, which allows for an acceleration of visits in a calendar quarter, is available:

• Following an accident that requires hospitalization;
• Following surgery; or
• Proactively to avoid surgery.

If you need more than 12 calendar quarter outpatient physical therapy, physical medicine or occupational therapy treatments following an accident that required hospitalization or following surgery, or proactively to avoid surgery, your referring physician will have to write a letter to the Plan specifying why the additional treatment is needed. The physician must also advise the Plan of the number of sessions that will be required, the frequency of treatments, and how long the therapy is anticipated to last. The Plan’s medical consultants will review your case, and advise you if extended therapy benefits will be provided, and the number of sessions that will be allowed.

The timeframes for accelerated visits differ based on the reason for therapy, as outlined below.

In no event will the Plan consider more than 48 sessions per calendar year for all types of therapy used.

Wellness Benefits
Plan I
Wellness benefits are provided to Plan I participants and their dependents without annual deductibles and age restrictions. You may see the doctor of your choice, in or out-of-network, subject to the appropriate co-payment ($15 for network charges or 20% of the Plan’s Allowance for non-network charges). The Plan will consider the following wellness services:

• Adult immunizations, including flu shots and travel immunizations – If no office visit is billed, no co-payment applies for network providers. The co-insurance does apply for non-network providers.
• Routine annual physicals.
• Well child exams – These include physical exams, diagnostic procedures and immunizations given as standard medical practice. In accordance with the American Academy of Pediatrics guidelines, these exams are limited to one per year after age two, though more frequent exams may be covered before that age.
• Well man exams – These are limited to one per year. The sigmoidoscopy and PSA test for cancer screening are covered separately if not done in conjunction with a routine annual physical.
• Well woman exams – The annual well woman exam, which routinely includes a mammogram and pap test, also includes bone density studies and is covered separately if not done in conjunction with a routine physical.

Plan II and Lower Cost Self-Pay Plan

Wellness benefits are available to Plan II participants and their dependents and individuals covered under the Lower Cost Self-Pay Plan, subject to annual deductibles and certain age restrictions. The Plan will consider the following wellness services:

• Network Providers Only
  • For individuals age 40 or over, a limited annual routine physical examination including a history and physical, routine lab work and Guaiac test. Allowable charges for this limited exam may also include additional appropriate medically necessary tests as prescribed by the network physician.
  • Well child care for children under the age of six. Well child care includes routine physical examinations, diagnostic procedures and immunizations given as standard medical practice. The Plan recognizes the guidelines established by the American Academy of Pediatrics to be the appropriate guidelines for the care and treatment of children. Exception: In areas where no network providers are available, the Plan will consider well child care provided by non-network providers.
• Network or Non-Network Providers
• Bone density test.
• Mammogram (limited to one per year
  unless diagnosis exists).
• Pap test (limited to one per year unless diagnosis exists).
• Routine colonoscopy (limited to once every 10 years starting at age 50 unless diagnosis exists).

Outpatient Nursing Benefits
For private duty outpatient nursing services, the Plan’s benefit is limited to 672 hours per person per calendar year. For example, this is equivalent to 28 days of nursing at 24 hours per day, or 56 days at 12 hours per day. The number of days of nursing allowable depends on the number of hours of nursing required per day. The allowance does not need to be used all at one time.

For example: If you use 150 hours of nursing at the beginning of the year, the balance of 522 hours is available for the remainder of the calendar year. Private duty nursing in excess of the 672 hours provided by the Plan may be considered by case management. Because the nursing benefit contains several restrictions, as described below, you should obtain approval before services are rendered. The amount allowed per visit will be determined by the Plan’s Reasonable Charge guidelines.

The Plan does not cover inpatient private duty nursing services under any circumstances.

Obtaining Approval for Private Duty Outpatient Nursing Care
Private duty nursing at home may be covered if you obtain advance approval as follows:

• The nursing services must be prescribed by your doctor as medically necessary for treatment of an illness or injury that is covered by the Plan.
• The level of nursing care must require a registered nurse (R.N.), licensed vocational nurse (L.V.N.), licensed practical nurse (L.P.N.) or equivalent state license who is not a relative or resident of your home.
• The nursing must not be for custodial or long term care. (See Glossary on page 91.)
• The doctor must submit a written diagnosis and treatment report within 14 days of the commencement of nursing services.
• Nursing notes must be submitted for review as claims are filed.

Medical consultants for the Plan will review the doctor’s report and nursing notes. If the nursing care is approved, the Plan will specify the number of days that it will cover, and the amount per visit that it will allow.

If your doctor prescribes private duty nursing care, please contact the Plan Office as soon as possible.

Services by Christian Science practitioners are not recognized as nursing services.

Case Management
One of the Health Plan’s most important tools in providing benefits for individuals with catastrophic illness or injury is the case management program. Case management offers a personal approach by which a coordinator works with the patient, the family and the attending physician to develop an appropriate treatment plan and to identify and suggest alternatives to traditional inpatient hospital care.

Some services that are not normally covered under the major medical benefits may be considered under the case management program. These include, but are not limited to, home nursing services, home physical and/or occupational therapy, durable medical equipment, and home health aide services. Skilled nursing facility and long term custodial care are not covered under the hospital benefit, the major medical benefit or case management. All services and equipment must be pre-authorized by the case management team.

The case management team at the Plan Office utilizes case management nurses at PHCS and Blue Cross to assist in approving and arranging necessary services and equipment, locating appropriate providers and negotiating rates with non-network providers.

Case management can help with a wide variety of catastrophic illnesses and injuries including burns, spinal cord injuries, multiple trauma injuries, cancer, cardiovascular disease, stroke, joint replacement post-surgical care, Acquired Immune Deficiency Syndrome, cerebral palsy and multiple sclerosis.

The case management team can also assist in arranging hospice care. If you feel the case management program is appropriate for you or your covered dependents you should contact the Plan Office as soon as possible.

The case management program is totally voluntary. Its purpose is to benefit the patient. Accordingly, if the patient, the physician and the family do not agree that the alternative plan is to the patient’s benefit, the patient does not have to participate. The program is provided as part of the benefit plan so there is no additional cost to participants or their eligible dependents.

Non-Covered Major Medical Expenses
(Includes all Practitioners)

• Acupuncture – Diagnostic services ordered or performed by a Certified Acupuncturist even if the provider is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
• Alcoholism or drug addiction treatment (except through ValueOptions as outlined on page 52 or when the Plan is secondary to another plan with a managed mental health and/or chemical dependency benefit as outlined on page 55).
• Breast pumps unless the newborn remains confined in the hospital because of an illness after the mother’s discharge and the physician orders continuing breast milk.
• Cervical traction units.
• Charitable hospitals – Treatment received in charitable hospitals.
• Chiropractic care – Diagnostic services ordered or performed by a chiropractor, (except spinal x-rays) even if the provider is duly licensed by a state agency and authorized to provide such services within the scope of his or her license.
• Cord blood storage charges.
• Cosmetic surgery, except where otherwise noted (see page 35 under “Major Medical Benefits” and page 38 under “Cosmetic Surgery”).
• Custodial care – Treatment received in custodial, convalescent, educational, rehabilitative care or rest facilities.
• Custodial nursing services.
• Cytotoxic testing.
• Dental services or appliances.
• Durable medical equipment – Equipment that does not meet the criteria outlined on page 91, or a second or duplicate piece of approved durable medical equipment for travel or convenience purposes.
• Electrolysis.
• Environmental equipment such as air filters, humidifiers and non-allergic bedding.
• Equipment and procedures not approved by the Food and Drug Administration.
• Exercise equipment, whirlpools, sunlamps, heating pads and other similar general use items, whether or not prescribed by your doctor.
• Food allergy antigens.
• Food supplements, herbs, minerals and other nutritional supplements.
• Gestational surrogate – Charges for services rendered to a gestational surrogate or to a fetus implanted into a gestational surrogate.
• Glasses, contact lenses or eye refractions (except following covered eye surgery as described on page 36 or as provided through VSP as described on page 60).
• Growth hormones (except when preapproved by the Plan under the prescription drug benefit as outlined on page 50).
• Health clubs, rolfing, alexander technique, feldenkrais, bioenergetics, posture realignment, pilates therapy or yoga.
• Homeopathic remedies.
• Hypnosis or hypnotherapy.
• Infertility treatment.
• Inpatient private duty nursing.
• Lactation specialists or consultants.
• Learning disabilities – Charges in connection with learning disabilities.
• Masseurs, masseuses, Massage Therapists (M.T.), Oriental Medical Doctors (O.M.D. or D.O.M. — one who practices oriental medicine), fitness instructors, dance therapists or colon hydrotherapists.
• Medical assistant therapists, aides or other providers not specifically licensed by the state to render physical or rehabilitative therapy, even though they are operating under the supervision of a covered provider.
• Medical necessity – Services or supplies not recognized as generally accepted medical practice or necessary for diagnosis or treatment.
• Modifications to a home or automobile to accommodate illness or injury.
• Naturopathic services, even if the provider is duly licensed in any state and authorized to provide medical services. Naturopathic services include conventional diagnosis, therapeutic nutrition, botanical medicine, homeopathy, naturopathic childbirth attendance, classical Chinese medicine, hydrotherapy, manipulation, pharmacology and minor surgery.
• Oral and topical medications dispensed in a physician’s office.
• Over-the-counter pregnancy tests.
• Personal comfort items while hospitalized, such as TV or telephone.
• Polysomnography (sleep studies) unless pre-approved by the Health Plan.
• Pregnancy for dependent children (complications of pregnancy are covered).
• Preventive medicine, including routine physical examinations or routine checkups (except as outlined on page 42).
• Professional fees for disorders listed in the Mental Disorders section of the current edition of the ICD.9.CM (International Classification of Diseases 9th Revision, Clinical Modification) publication, regardless of the basis of the disorder, or the diagnosis (except as provided through Value-Options as outlined on page 52 or when the Plan is secondary to another plan with a managed mental health and/or chemical dependency benefit as outlined on page 55).
• Psychiatrist or Psychopharmacologist for drug management, regardless of the basis of the disorder or the diagnosis (except as provided through ValueOptions as outlined on page 52 or when the Plan is secondary to another plan with a managed mental health and/or chemical dependency benefit as outlined on page 55).
• Psychotherapy (except as provided through ValueOptions as described on page 52 or when the Plan is secondary to another plan with a managed mental health and/or chemical dependency benefit as described on page 55).
• Reversal of vasectomy or tubal ligation.
• Smoking cessation programs.
• Surgical correction of a bite defect.
• Surgical procedures to correct a refractive error such as LASIK, photorefractive keratectomy (PRK), radial keratotomy or radial thermocoagulation (RTK).
• Vitamins. However, if you or your dependent are not able to assimilate medication ordinarily prescribed for treatment of an illness, the Plan may consider covering the vitamins, subject to medical review.
• Weight control or weight loss programs, regardless of any underlying medical condition for which they may be prescribed.

See also “General Exclusions” on page 64.