The Consumer Choice Plan covers the following medical care expenses in 2009:
- Acupuncture services are covered if rendered by a licensed provider and the services are for:
o Anesthesia in connection with a surgical procedure covered by the plan.
o Chronic pain associated with the following conditions: Arthritis, menstrual pain and irregularity, back pain, migraine, lumbago, pinched nerve, sciatica, post laminectomy, slipped disc, rheumatism, Bell’s palsy, spastic colon, bursitis, stroke, dysmenorrhea, tennis elbow, headaches, tendonitis, herpes zoster, and trigeminal neuralgia.
o Nausea related to chemotherapy or pregnancy.
- Allergy care when administered by a physician, allergist or specialist. Serum is covered only when received and administered within the provider’s office. If received from a pharmacy, the serum may be covered under the pharmaceutical benefit. The following services are covered:
○ Tests, including skin, scratch and radioallergosorbent (RAST) tests; and
○ Injections, including immunotherapy.
- Ambulance (air) services when:
○ Used to transport to a hospital or from one hospital to another because the first hospital does not have the required services and/or facilities to treat the patient; and ground transportation is not medically appropriate because of the distance involved; or
○ The patient has an unstable condition requiring medical supervision and rapid transport.
- Ambulance (ground) services when:
○ Used to transport the patient from the place of accidental injury or serious medical incident to the nearest facility;
○ Used to transport a patient from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the patient;
○ Used to transport a patient from hospital to home, skilled nursing facility or nursing home when the patient cannot be safely or adequately transported in another way without endangering the individual’s health;
○ Used to transport a patient from home to hospital for inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the patient; or
○ To transport a patient upon medical stabilization from a non-discounted facility to a discounted facility when they were admitted due to a medical emergency to a non-discounted facility.
- Anesthesia other than local infiltration anesthesia in connection with a covered surgical procedure, provided the anesthesia is administered and charged for by a physician other than the operating surgeon or his assistant.
when used to treat conditions and diseases ranging from stress; alcohol and other addictions; sleep disorders; epilepsy; respiratory problems; fecal and urinary
muscle spasms; partial paralysis or muscle dysfunction caused by injury; migraine headaches; hypertension; and a variety of vascular disorders.
to maintain or replace blood volume, to provide deficient blood elements and improve coagulation, to maintain or improve transport of oxygen, and in exchange for blood that has been removed in the treatment of Rh incompatibility in the newborn, liver failure in which toxins accumulate in the blood, or in some other types of toxemia. Coverage is included for the following:
○ Autologous;
○ Direct donation;
○ Regular administration; and
○ Blood products.
as follows:
○ Phase I begins during/after the acute event (i.e. bypass surgery, myocardial infarction, angioplasty). It includes nursing services, physical therapy and teaching the patient how to deal with the condition.
○ Phase II is a hospital based outpatient program after inpatient hospital discharge. It is physician directed with active treatment and EKG monitoring at a frequency of three times per week for approximately 12 weeks.
- Chemotherapy treatment of malignant disease by chemical or biological antineoplastic agents. The cost of the antineoplastic agent is included.
- Charges of a surgeon and assistant surgeon for covered surgical procedures. Note that when multiple procedures are performed at the same time, the second procedure will be paid at 50% up to the recognized charge. Medically necessary charges for the assistant surgeon will be paid up to 20% of the covered charge for the surgical procedure.
- Chiropractic services for the detection and correction of nerve interference, resulting from or related to misalignment or partial dislocation of or in the vertebral column, by manual or mechanical means. Benefits for chiropractic treatment are limited to a maximum of 24 visits (includes visits that occur before you meet your deductible that may not receive any payment) per person per calendar year.
- Dental care, as follows:
○ Charges for care rendered by a physician or dentist, which are required as a result of an accidental injury to the jaws, sound natural teeth, mouth or face, provided care begins within 90 days of the accident. Injury as a result of chewing or biting will not be considered an accidental injury; and
○ Charges for surgical benefits for cutting procedures for the treatment of disease, injuries, fractures and dislocations of the jaw when the service is performed by a physician or dentist are also considered covered services.
Note: Normal extraction and care of teeth and structures directly supporting the teeth are not covered; however may be covered under the dental plan option, if enrolled.
- Diagnostic X-rays and complex imaging services provided on an outpatient basis when performed to diagnose specific symptoms or rule out medical conditions, including but not limited to:
○ Diagnostic X-ray, consisting of radiology, ultrasound, nuclear medicine and magnetic resonance imaging;
○ Diagnostic laboratory and pathology tests;
○ Diagnostic medical procedures consisting of EKG, EEG and other electronic diagnostic medical procedures; and
○ Pre-admission pre-surgical tests which are made prior to a covered person’s inpatient or outpatient surgery.
- Dialysis—treatment of acute renal failure or chronic irreversible renal insufficiency for removal of waste materials from the body, to include hemodialysis or peritoneal dialysis.
- Durable medical equipment as defined on page 152 examples of covered expenses include:
Man-made limbs or eyes to replace natural limbs or eyes;
Casts, orthopedic splints or crutches;
Trusses or braces required as a result of an injury or illness, or a disabling condition existing since birth;
Rental of equipment for giving oxygen or to aid in breathing if the equipment has a mouthpiece, hose and compressor;
Temporary rental (up to the purchase price) of wheelchairs or hospital beds or purchase of wheelchairs or hospital beds if the patient’s condition requires an indefinite, prolonged period of use;
Dialysis equipment rental, supplies, upkeep and training for you or your dependents to use this equipment;
Ostomy bags and supplies;
Glucometers, dextrometers, dextrostix and rental of infusion pumps and supplies;
Adaptive equipment or modifications to wheelchairs or hospital beds, which are prescribed by a physician as necessary for the treatment of the injury or illness; and
Medically necessary insulin and diabetic supplies.
Benefits will also be provided for adjustments, repair and replacements of covered prosthetic devices, special appliances and surgical implants when required because of wear or change in a patient’s condition (excluding dental appliances and post mastectomy holding bra).
- Drugs, medicines and supplies used for treatment of erectile dysfunction due to vasculogenic or neurogenic causes. Dosage is limited to six tablets for a 30-day supply through a retail pharmacy or 18 tablets for a 90-day supply through a mail service pharmacy.
for the initial treatment of a life- or limb-threatening injury or illness. This includes emergency room and urgent care facilities and professional provider services and supplies.
- Expenses relating to pregnancy for an employee or covered dependent spouse or domestic partner. No benefits are payable for expenses relating to the pregnancy of a dependent child/child of domestic partner; however expenses relating to complications of pregnancy or delivery are covered.
- Family planning services, including:
○ Injectable contraceptives and contraceptive devices provided in a doctor’s office;
○ Tubal ligation;
○ Vasectomy; and
○ Sterilization.
- Hearing care, including one hearing exam per calendar year and hearing aids and associated fitting services (up to an $800/lifetime maximum benefit for the hearing aids).
- Home health care expenses if:
○ The charge is made by a licensed home health care agency; and
○ Care is given under a home health care plan; and
○ Care is given to a person in his or her home.
Home health care includes:
○ Part-time or intermittent care by an R.N. or by an L.P.N. if an R.N. is not available;
○ Part-time or intermittent home health aide services for patient care;
○ Physical, occupational and speech therapy;
o The following to the extent they would have been covered under this plan if the person had been confined in a hospital or convalescent facility:
- Medical supplies;
- Drugs and medicines provided by a physician; and
- Lab services provided by a home health care agency.
Care must be precertified as described on page 23. Private duty nursing is covered if provided by an R.N. or an L.P.N. if an R.N. is not available. Home health care benefits are not payable for:
○ Custodial care;
○ Transportation service;
○ Services of someone who lives with the patient or who is a member of your or your spouse’s or domestic partner’s family;
○ Services not included in the written home care plan of the physician of record; or
○ Services rendered at a time when the patient is not under the care of the physician who set up the home care plan.
- Hospice care benefits during a terminal illness (where life expectancy is less than six months). Care must be precertified as described on page 23. Benefits are paid for up to six months from the date the hospice care plan is established, not to exceed the maximum lifetime inpatient and outpatient care combined benefit (180 days). The hospice care benefit includes a limited benefit for respite care and a limited benefit for bereavement counseling for immediate family members during the six-month period following the date of death as provided by the hospice.
Hospice care benefits are not payable for:
○ Services provided by persons who do not regularly charge for their services;
○ Counseling which is not provided as part of the hospice care plan;
○ Services provided by homemakers, caretakers and similarly situated individuals;
○ Funeral expenses;
○ Treatment intended to cure the terminal illness; or
○ Financial or legal counseling, estate planning and the drafting of a will.
- Hospital expenses, including daily room and board charges for a semi-private room, general nursing care and intensive care unit (ICU). If a facility with no semi-private rooms, the covered charge is limited to the lowest room rate. Coverage includes all other medically necessary miscellaneous services and supplies furnished by a hospital during covered inpatient hospital confinement.
- Infertility treatment for the initial evaluation and correction of the underlying condition only. Procedures that may produce a pregnancy, but do not correct the underlying cause of the infertility are not covered.
- Mammographic screening, including clinical breast exam and mammogram—covered once per calendar year starting at age 35.
- Mastectomy and charges related to a covered mastectomy in accordance with the Women’s Health and Cancer Rights Act, including:
○ Treatment of physical complications during any stage of the mastectomy, including lymphedemas;
○ Reconstruction of the breast on which the mastectomy has been performed;
○ Surgery and reconstruction on the non-diseased breast to attain the appearance of symmetry between the two breasts; and
○ Breast prostheses.
- Medically necessary services and supplies furnished in a licensed ambulatory surgical center or birthing center.
- Mental health and substance or chemical dependency abuse services, precertified as described on page 23, including:
Inpatient (limited to 30 days per calendar year in-network and out-of-network combined)
○ Treatment that includes 24-hour nursing and daily, active treatment under the direction of a psychiatrist, or for children and adolescents, a board certified/eligible child and adolescent psychiatrist.
○ Charges of a facility and/or professional provider related to or because of psychiatric illness are covered as follows:
- Inpatient facility charges;
- Individual psychotherapy;
- Group psychotherapy;
- Psychological testing;
- Family counseling (counseling with family members to assist in the covered person’s diagnosis and treatment); and
- Electro-convulsive therapy (electroshock treatment) or convulsive drug therapy, including anesthesia when administered concurrently with the treatment by the same professional provider.
Outpatient (limited to 45 visits per calendar year in-network and 20 visits per calendar year out-of-network. Limits cross-apply.)
○ Diagnosis or treatment of a mental disease, disorder, or condition, whether or not the cause of the disease, disorder, or condition is physical, chemical or mental in nature or origin. Care must be provided by a physician or licensed mental health/chemical dependency provider. Covered services include but are not limited to:
- Assessment;
- Diagnosis;
- Individual, group, family or conjoint psychotherapy;
- Medication management;
- Psychological testing and assessment;
- Electroconvulsive treatment (ECT);
- Crisis intervention; and
- Rehabilitation (drug and alcohol related).
o ECT, medication management, biofeedback treatments for mental health, and methadone maintenance treatments are covered under this benefit, but do not apply to the outpatient mental health/chemical dependency limits.
Alternative levels of care
Alternative levels of care are covered as follows and apply to the calendar year maximum limits:
○ Acute partial hospitalization: Includes daily nursing and active treatment in a structured treatment program lasting 5-7 days per week and delivering at least 20 hours of active
○ treatment per week, with patients going home each evening and/or weekend (each day of partial hospitalization counts as one-half day of inpatient treatment);
○ Residential treatment center is medically supervised, psychiatric residential treatment—a level of care that includes individualized and intensive treatment on a 24-hour basis in a residential setting; and
○ Intensive outpatient treatment (IOP): IOP is a structured program that includes combinations of individual and group process therapy, meeting at least three times per week, and delivering at least 4 hours of treatment per week.
- Naturopath services—office visits to a licensed naturopath are covered. Surgical procedures, injections, medicine, herbs, supplements and vitamins dispensed by a naturopath are not covered.
- Nutritional counseling, including services rendered by a registered dietician, or other licensed provider, for individuals with medical conditions that require a special diet. Some examples of such medical conditions include diabetes mellitus, coronary heart disease, congestive heart failure, severe obstructive airway disease, gout, renal failure, phenylketonuria and hyperlipidemias. Coverage for nutritional counseling is limited to six visits per person per calendar year.
- Orthotic devices, including custom molded inserts, if prescribed by a physician.
- Outpatient charges for medical care and supplies used on the premises of a hospital.
- Podiatry surgery and services, including incision and drainage of infected tissue of the foot; removal of lesions of the foot; removal or debridement of infected toenails; and treatment of fractures and dislocations of bones of the foot. Procedures considered to be a part of a routine foot care, or of a cosmetic nature, such as treatment of corns, calluses, non-surgical care of toenails, fallen arches and other symptomatic complaints of the feet are not covered.
- Post-delivery inpatient hospital care for a mother and her newborn child, regardless of whether or not the birth occurred in a hospital.
- Pre-admission testing performed before a scheduled inpatient hospital admission.
- Preventive care services, including screening tests, immunizations and counseling services designed to detect and treat medical conditions to prevent avoidable premature injury, illness and death. Covered expenses include:
Baby/child preventive care office visits:
○ Six visits in the first year;
○ Three visits in the second year; and
○ One visit per calendar year from ages 2 and up.
Baby/child screening tests (per calendar year, unless otherwise indicated):
○ Lead level tests (once between 9 and 12 months);
○ Vision screenings; and
○ Hearing screenings.
Baby/child immunizations:
○ Hepatitis A;
○ Hepatitis B;
○ Diphtheria, tetanus, pertussis (DtaP);
○ H. influenza type b;
○ Polio;
○ Measles, mumps, rubella (MMR);
○ Varicella (chicken pox);
○ Influenza—flu shot (over age 6 months);
○ Pneumococcal conjugate (pneumonia); and
○ Human Papillomavirus (HPV) – up to age 26.
Adult preventive care office visits
○ Periodic preventive visit (one per calendar year visit)
Adult screening tests (per calendar year, unless otherwise indicated):
○ Periodic cholesterol and lipid screening – every 12 months*;
○ Clinical breast exam and mammogram: one per calendar year starting at age 35;
○ Routine pelvic exam, Pap test and contraceptive management – every 12 months*;
○ Fecal occult blood testing, one per calendar year;
○ Flexible sigmoidoscopy every 5 calendar years;
○ Colonoscopy every 7 calendar years (excluding virtual colonoscopy);
○ Prostate cancer screenings: digital rectal examination (DRE) and prostate specific antigen (PSA) at discretion of physician and patient – every 12 months*;
○ Blood glucose testing, one per calendar year; and
○ Bone density screening age 60 and over – every 12 months*.
*Every 12 months means…
There is at least 12 months between the same service. For example, if you had a lipid screening test in February 2009, you would not be eligible for another covered lipid screening until March 2010.
Adult immunizations
○ Influenza;
○ Pneumococcal conjugate (pneumonia);
○ Tetanus /diphtheria (DtaP);
○ Measles, mumps, rubella (MMR);
○ Hepatitis A;
○ Hepatitis B and Varicella;
○ Human Papillomavirus – up to age 26; and
○ Meningococcal.
on an outpatient basis only, up to 120 visits per calendar year. Nursing services must be rendered by a nurse who does not reside in the patient’s home, or who is not a member of the immediate family. To be covered, the physician in charge of the case must certify that the patient’s condition requires the requested care, which can only be provided by an RN or LPN. Private duty nursing applies only for care given in the patient’s home and not part of the home health care agency’s plan of treatment.
- Professional service charges of a physician.
- Radiation therapy—The treatment of disease by X-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes.
- Respiratory therapy—The introduction of dry or moist gases into the lungs for treatment purposes.
- Therapy, up to 60 total visits per person per calendar year, as follows:
○ Physiotherapy services of a physiotherapist;
○ Services of a qualified speech therapist to restore speech loss or correct impairment due to congenital defect, illness or injury.
○ Physical therapy; and
○ Occupational therapy.
- Skilled nursing facility charges when care is precertified as described on page 23. Maximum covered daily charge based on semi-private room charge at facility.
- Transplants:
Transplants for all participants enrolled in the Consumer Choice plan will be referred to the Blue Distinction Centers for Transplants for coordination of some solid organ, bone marrow, and stem cell transplants. Contact your claims administrator for information regarding transplant benefits.
Transplants available at a Blue Care Distinction Center are eligible for coverage on an in-network basis. If a transplant available at a Blue Care Distinction Center is performed at any other facility (whether an in-network facility or not), coverage is only available on an out-of-network basis. For transplants not available at a Blue Care Distinction Center, normal network rules apply, i.e., services performed at a network facility are payable in-network and those performed at a non-network facility are payable on an out-of-network basis.
Covered services include:
○ Hospital and physician services for the surgical removal of a human organ or tissue from a living donor to a transplant recipient only if:
- The transplant recipient and donor are both enrolled for coverage under the plan. In this case, benefits will be provided for both patients under the recipient’s coverage; or
- The transplant recipient is enrolled for coverage under the plan. In this case, benefits will be provided for the recipient. Benefits may also be provided for the donor for covered expenses under the recipient’s coverage (to the extent of any benefits remaining after payment of the recipient’s expenses), but only if those services are not eligible under any other coverage available to the donor.
These expenses are covered in connection with the specific organ and bone marrow transplants for a plan participant only if:
- The recipient of the transplant is a medical plan participant;
- The transplant is medically appropriate, non-experimental and represents the preferred method of treatment;
- The participant satisfies the criteria of the participating hospital for the transplant; and
- The medical plan participant precertifies the transplant with the claims administrator.
Transplants that may be covered include the following:
○ Bone marrow/stem cell;
○ Cornea;
○ Kidney;
○ Liver;
○ Heart;
○ Heart/lung;
○ Kidney/pancreas;
○ Liver/small bowel;
○ Lung;
○ Pancreas; and
○ Small bowel.
If the donor is enrolled for coverage under the plan but the transplant recipient is not; expenses for services rendered to the donor and to the transplant recipient will not be considered covered expenses under the plan.
Limited expenses for travel, lodging and meals may also be covered if you are enrolled in the Consumer Choice Plan administered by Anthem Lumenos. Contact the claims administrator for details.
Experimental transplants, investigational transplants or transplants that are determined not medically appropriate by the claims administrator and the plan administrator will not be covered.
- Wigs after chemotherapy, alopecia, radiation therapy or surgery. Benefits are limited to a lifetime maximum of $500 per person.
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Questions about your employee benefits or other Human Resources issues? Contact the Workplace Solutions Center at (888) 471-2271.