The Medical Plan reimburses expenses for the following services and products, when they are medically necessary, at the levels shown in "Highlights of the Plan" and "Benefit Summary." The amount the Plan pays may be limited by provisions explained in the sections "Expenses That Are Not Eligible" and "Allowable Charge."
Acupuncture: Charges for acupuncture services limited to 25 treatments per calendar year.
Ambulatory Surgical Facility Services: Charges for ambulatory hospital-type services, not including physicians' services, given to you in and by an ambulatory surgical facility only when:
- An operative or cutting procedure which cannot be done in a physician's office is actually performed, and
- The operative or cutting procedure is an eligible expense.
Ambulance Services: Charges for medically necessary transportation (ground or air) by means of a specially designed and equipped vehicle used only for transporting the sick and injured:
- From your home to a hospital,
- From the scene of an accident or medical emergency to a hospital,
- Between hospitals,
- Between a hospital and a skilled nursing facility, or
- From the hospital to your home.
Such transportation is limited to local transportation to the closest facility appropriate for your condition. If none, you are covered for trips to the closest such facility outside your local area.
Anesthetics: Charges for anesthetics and their administration in or out of the hospital by a physician or other provider who is not the surgeon or the assistant surgeon.
Baby Care Checkups: Charges for checkups for children through age six. (Expenses for baby care checkups without immunizations are reimbursed at the outpatient visits benefit level. Expenses for baby care checkups, including related lab tests that include immunizations, are reimbursed at the preventive care benefit level shown in "Benefit Summary.")
Chiropractic Services: Charges for the diagnosis and treatment of mechanical disorders of the musculoskeletal system and other disorders by manipulation of the spine or other areas of the body, and related services. Chiropractic Services includes such services provided by a licensed chiropractor, osteopath, or any other medical professional.
Clinical Trials: Routine patient costs for items and services furnished to "qualified individuals" in connection with participation in an approved clinical trial. To facilitate benefit payment, when you begin the trial, please notify Care Coordination by calling Member Services at (855) 979-5192.
Routine patient costs include items and services consistent with the coverage provided under the Plan that are typically covered for a qualified individual who is not enrolled in a clinical trial but do not include: (i) the item, device, or service that is itself being investigated; (ii) items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; or (iii) a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis.
You are a "qualified individual" if you are eligible, according to the trial protocol, to participate in an approved clinical trial for the treatment of cancer or other life-threatening disease or condition and either the referring health care professional has concluded that your participation in the clinical trial would be appropriate; or you provide medical and scientific information establishing that your participation in the clinical trial would be appropriate.
An approved clinical trial is a phase I, phase II, phase III, or phase IV clinical trial that is conducted in connection with the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is (1) federally funded through any of a variety of entities or departments of the federal government that are identified in 42 U.S.C. § 300gg-8; (2) conducted in connection with an investigational new drug application reviewed by the Food and Drug Administration; or (3) exempt from investigational new drug application requirements. A life-threatening condition is a disease or condition likely to result in death unless the disease or condition is interrupted.
- Placed or prescribed by a physician,
- Intended primarily for the purpose of preventing human conception, and
- Approved by the U.S. Food and Drug Administration (FDA) as acceptable methods of contraception.
Examples include Norplant, intrauterine devices (IUDs), diaphragms, and Depo-Provera. See the Prescription Drug Plan section for information about coverage for oral contraceptives.
Cosmetic treatment to restore normal physical function: Charges for cosmetic treatment generally are not eligible. However, if preauthorized and found to be medically necessary, the following cosmetic treatments for diagnosed conditions to restore normal physical function are covered at 50% of Allowable Charges (after deductible):
- Botox® or any equivalent to treat hyperhidrosis
- Liposuction for lipedema class III or IV
If preauthorized and found to be medically necessary for a diagnosis other than hyperhidrosis, the use of Botox® or any equivalent for treatment of such diagnosis will be covered at the Alliance Direct and Non-Direct benefit levels, as applicable.
Dental Care to Treat Accidental Injury: Charges for dental services for accidental injury to the jaws, sound natural teeth, mouth, or face within 365 days after the accident (expenses for other dental services may be covered by the Dental Plan). Injury caused by chewing or biting an object or substance placed in your mouth is not considered an accidental injury, regardless of whether you knew the object or substance was capable of causing such injury if chewed or bitten. Dental implants, including preparation for implants, and stem cell tooth regeneration are not eligible for coverage under this provision.
Dental-Related Services for a Member with Special Needs Requiring Hospital Services or Ambulatory Surgical Facility Services: Subject to preauthorization requirements, hospital services, ambulatory surgical facility services, and anesthesia services associated with any medically necessary dental procedure when provided to a member who is severely disabled or eight years of age or under, and who has a medical or emotional condition which requires hospitalization, general anesthesia, or IV anesthesia/sedation for dental care.
Durable Medical Equipment (DME): Charges for the rental (or, at the Plan's option, the purchase) of durable medical equipment, provided such equipment meets the following criteria:
- It provides therapeutic benefits or enables the patient to perform certain tasks that he or she would be unable to perform otherwise due to certain medical conditions and/or illness,
- It can withstand repeated use and is primarily and customarily used to serve a medical purpose,
- It is generally not useful to a person in the absence of an illness or injury and is appropriate for use in the home, and
- The claim is submitted to the Plan by a licensed DME provider using a Plan-approved claim form (or, if the claim is submitted by a member, the equipment must be prescribed by a physician).
Examples of durable medical equipment are:
- Canes, crutches, and walkers
- Dialysis machines
- Insulin pumps (limited to one every three years)
- Oral appliances, continuous positive airway pressure (CPAP) machines, or bi-level positive airway pressure (BiPAP) machines for obstructive sleep apnea (limited to one every three years)
- Oxygen, bottled or concentrator (concentrators limited to one every five years; any fees charged to fill oxygen containers are not covered)
- Portable CPAP or BiPAP machines, covered only for employees who travel frequently as a job requirement (Allowable Charge limited to $500, one every five years)
- Traction equipment
Also included are repairs, maintenance, and costs of delivery of equipment, as well as expendable and non-reusable items essential to the effective use of the equipment. Such repair and replacement is not included if the equipment is lost, stolen, damaged, or destroyed unless approved by the Plan Administrator.
Certain items, although durable in nature, may fall into other coverage categories, such as prosthetic appliances or orthotic devices.
Certain types of durable medical equipment are subject to preauthorization requirements; see "Appendix C: Services and Products that Require Preauthorization."
To find an Alliance Direct provider of durable medical equipment, call Member Services at (855) 979-5192. In addition, certain durable medical equipment is covered at the Alliance Direct benefit level when arranged by Care Coordination or provided by an on-site clinic.
The Plan will pay rental fees only for durable medical equipment that is in continuous use by the participant as prescribed.
Extraction of Impacted Teeth: Charges for removal of impacted teeth.
Genetic Testing: Charges for genetic-related tests required for a medical determination for a specific treatment. The testing must be ordered by a physician to establish diagnosis, determine prognosis, and/or provide information that will improve treatment or change outcomes. Preauthorization is required for the types of genetic testing listed in “Appendix C: Services and Products that Require Preauthorization” (this list is updated periodically). In all cases, genetic testing must be billed under a listed procedure code.
Home Health Care: Subject to preauthorization requirements, charges for the following services and products you receive from a hospital program for home health care or community home health care agency, provided such care is prescribed by a physician:
- Medical and surgical supplies
- Prescribed drugs
- Up to 120 visits (not to exceed four hours per visit) per calendar year per member, limited to the following:
- Professional services of an RN, LPN, or LVN
- Medical social service consultations
- Health aide services while you are receiving covered nursing or therapy services
The following services and products may be covered as part of home health care, but only if each service is specifically preauthorized:
- Dietitian services
- Homemaker services
- Maintenance therapy
- Physical therapy, speech therapy, or occupational therapy (subject to the "Rehabilitation or Habilitation" limit shown in "Benefit Summary"
- Durable medical equipment (rental or purchase, at the Plan's option)
- Food or home-delivered meals
- Intravenous drug, fluid, or nutritional therapy
- Oxygen and its administration (excluding any fees charged to fill oxygen containers)
To be eligible for the Alliance Direct benefit level (if available in your area), home health care services must be coordinated through Care Coordination.
Hospice: Subject to preauthorization requirements, charges for hospice care for a patient who has been diagnosed as terminally ill, provided the attending physician submits a written hospice care plan. To be eligible for the Alliance Direct benefit level (if available in your area), hospice services must be coordinated through Care Coordination.
Hospital Services: Charges for the following services, products, and supplies you receive from a hospital or other eligible provider (such as an ambulatory surgical facility or birthing center), subject to preauthorization requirements and subject to the limitations described below:
- Bed and board: Bed, board, and general nursing service in:
- A room with two or more beds
- A private room (private room allowance is equal to the most prevalent semiprivate room charges of your hospital). Private room charges in excess of the semiprivate room allowance will not be eligible for benefits unless the patient is required under the infection control policy of the hospital to be in isolation to prevent contagion
- A bed in a special care unit which gives intensive care to the critically ill
- Ancillary charges
- Operating, delivery, and treatment rooms
- Prescribed drugs
- Whole blood, blood processing, and administration
- Anesthesia supplies and services rendered by an employee of the hospital or other provider
- Medical and surgical dressings, supplies, casts, and splints
- Oxygen (home and/or portable oxygen requires preauthorization; any fees charged to fill oxygen containers are not covered)
- Subdermally implanted devices or appliances necessary for the improvement of physiological function
- Diagnostic services
- Therapy services (benefits for speech therapy are limited to inpatient services only)
- Emergency accident care: Outpatient emergency hospital services and supplies to treat injuries caused by an accident
- Emergency medical care: Outpatient emergency hospital services, products, and supplies to treat a sudden and acute medical condition that requires prompt medical care
- Surgery: Hospital services, products, and supplies for outpatient surgery furnished by an employee of the hospital or other provider other than the surgeon or assistant surgeon
- Routine nursery care
- Inpatient hospital services for routine nursery care of a newborn member
- Routine nursery care does not include treatment or evaluation for medical or surgical reasons during or after the mother's maternity confinement. In the event the newborn requires such treatment or evaluation while covered under the Plan:
- The infant will be considered as a member in its own right and will be entitled to the same benefits as any other member. Accordingly, preauthorization is required if a newborn’s inpatient stay will extend beyond 48 hours following a vaginal delivery, or 96 hours following a cesarean section. The preauthorization request must be made for the newborn within two business days following the end of the 48-hour period (for a vaginal delivery) or 96-hour period (for a cesarean section) to avoid a benefit penalty.
- A separate deductible, if applicable, will apply to the newborn's hospital confinement.
Benefits are not provided for routine nursery care or other care for an infant born to a dependent child.
Coverage for inpatient hospital services is limited to 180 days per calendar year.
Immunizations: Charges for routine immunizations including the related office visit, with no age restrictions, provided they are administered in a physician's office, at a state or local health department or pharmacy, or during a medical emergency.
Infusion Services: Charges for infusion services (e.g., chemotherapy, biological therapy) subject to preauthorization requirements. In addition to the benefit levels shown in “Benefit Summary,” the Plan pays 100% of Allowable Charges for infusion services when the services are provided at an Alliance Direct provider, an on-site clinic, or an alternate site (including at-home administration) arranged through Care Coordination.
Medical Services (including Surgery): Charges for the following services and products you receive from a physician or other provider. Inpatient admissions, as well as outpatient procedures, are subject to preauthorization requirements.
- Surgery, including visits before and after surgery:
- If an incidental procedure (a procedure carried out at the same time as a primary surgical procedure, but which is clinically integral to the performance of the primary procedure, and, therefore, should not be reimbursed separately) is carried out at the same time as a more complex primary procedure, then benefits will be payable for only the primary procedure. Separate benefits will not be payable for any incidental procedures performed at the same time.
- When more than one surgical procedure is performed through more than one route of access during one operation, you are covered for:
- The primary procedure, plus
- 50% of the amount payable for each of the additional procedures had those procedures been performed alone.
- Sterilization, regardless of medical necessity
- Charges for the use of a robotic surgical system (for example, robot-assisted prostate surgery) are not eligible expenses, unless such charges are specifically preauthorized by the Plan.
- Assistant Surgeon: Services of a physician who actively assists the operating surgeon in the performance of covered surgery, but not for a robotic device billed as an assistant surgeon; if an assistant surgeon is required, the Allowable Charge for the assistant surgeon’s services will not exceed the percentage of the Allowable Charge for the primary surgeon’s services as determined in the agreement with the Alliance Direct provider, if applicable, or as determined under the Medicare reimbursement rules for the applicable service
- Anesthesia: Administration of anesthesia by a physician or other provider who is not the surgeon or the assistant surgeon
- Inpatient Medical Services
- Medical care when you are an inpatient for a condition not related to surgery, pregnancy, or mental illness, except as specified
- Inpatient medical care visits (limited to one visit or other service per day by the attending physician)
- Intensive medical care: Constant physician attendance and treatment when your condition requires it for a prolonged time
- Concurrent care: Care for a medical condition by a physician who is not your surgeon while you are in the hospital for surgery if the nature of the illness or injury requires care by two or more physicians during one hospital stay
- Consultation by another physician when requested by your attending physician, limited to one visit or other service per day for each consulting physician; staff consultations required by hospital rules are excluded
- Newborn well baby care: Routine nursery care visits to examine a newborn member, limited to the first 48 hours following a vaginal delivery or 96 hours following delivery by cesarean section. No additional inpatient visits are covered for well-baby care. Preauthorization is required if a newborn’s inpatient stay will extend beyond 48 hours following a vaginal delivery, or 96 hours following a cesarean section. The preauthorization request must be made for the newborn within two business days following the end of the 48-hour period (for a vaginal delivery) or 96-hour period (for a cesarean section) to avoid a benefit penalty.
- Outpatient Medical Services: Outpatient medical care that is not related to surgery, pregnancy, or mental illness, except as specified:
- Emergency accident care: Treatment of accidental bodily injuries
- Emergency medical care: Treatment of a sudden and acute medical condition that requires prompt medical care
- Home, office, and other outpatient visits: Visits and consultation for the examination, diagnosis, and treatment of an injury or illness; telehealth is covered in accordance with the Plan's Telemedicine and COVID-19 policy
- Diabetes treatment: Equipment, supplies, and related services for the treatment of Type I, Type II, and gestational diabetes when recommended or prescribed by a physician or other provider (see the Prescription Drug Plan section for information about coverage for diabetic supplies)
- Audiological services and hearing aids, when prescribed, filled, and dispensed by a licensed audiologist, are limited to:
- Audiology screening/testing, once a year, regardless of age or diagnosis,
- One hearing aid per ear every 48 months for members up to age 18, and
- Up to four additional ear molds per calendar year for members up to two years of age.
Medical Supplies: Charges for blood and blood products, sterile dressings for burns and cancer, catheters, colostomy bags and related supplies, and oxygen and related equipment (home and/or portable oxygen requires preauthorization; any fees charged to fill oxygen containers are not covered). (For information about coverage for diabetic supplies, see the Prescription Drug Plan section.)
Benefits will not be provided for both an inpatient medical care visit and individual psychotherapy when performed on the same day by the same physician.
Mental Health and Substance Abuse Treatment: Charges for the following services and supplies you receive from a provider to treat mental illness or substance abuse:
- Video-conference or other telehealth consultations coordinated through on-site clinic or in accordance with the Plan's Telemedicine and COVID-19 policy
- Inpatient facility services (subject to preauthorization requirements): Covered inpatient facility services provided by a hospital or residential treatment center
- Inpatient medical services (subject to preauthorization requirements): Covered inpatient medical services provided by a physician or other provider:
- Medical care visits limited to one visit or other service per day
- Individual psychotherapy
- Group psychotherapy
- Psychological testing
- Convulsive therapy treatment: Electroshock treatment or convulsive drug therapy including anesthesia when given together with treatment by the same physician or other provider
- Coverage for inpatient hospital and/or residential treatment center services is limited to 180 days per calendar year, combined.
- Outpatient psychiatric care services
- Facility and medical services: Covered inpatient facility and medical services when provided for the outpatient treatment of mental illness by a hospital, residential treatment center, physician, or other provider (which includes a psychiatrist, psychologist, other health care provider who is acting within the scope of that provider’s license or certification under applicable state law, or a person with a master’s degree in social work)
- Day/night psychiatric care services: Services of a Plan-approved facility on a day-only or night-only basis in a planned treatment program
- Drug abuse and alcoholism: Benefits for the treatment of mental illness include treatments for drug abuse and alcoholism
- Intensive outpatient care (subject to preauthorization requirements)
- Outpatient partial hospitalization (subject to preauthorization requirements)
Benefits will not be provided for both an inpatient medical care visit and individual psychotherapy when performed on the same day by the same physician.
A facility providing rehabilitation services must be: (i) licensed to provide such services by the state (or other jurisdiction, if applicable) in which it is operating; and (ii) accredited by a recognized accrediting body (as determined by the Plan Administrator) or, if outside the United States, licensed or approved by the foreign government or an accreditation or licensing body working in that foreign country.
Nutritional Counseling: Charges for office visits by a registered dietician or other licensed provider for nutritional counseling.
Nutritional Substances: Subject to preauthorization requirements, charges for nutritional substances administered other than by mouth and charges for their administration (enteral nutritional therapy), if prescribed by a physician in situations where you have a life-threatening condition and are unable to take ordinary food. The Plan has the right to require that nutritional substances be purchased from an over-the-counter (OTC) source or other provider, rather than the nutritional therapy provider.
Obesity Counseling: Charges for office visits with licensed providers for obesity counseling and discussion of obesity treatment options. Prescription drugs to treat obesity may be covered under the Prescription Drug Plan. However, charges for all other obesity treatments — such as weight loss treatments, bariatric surgery, inpatient/outpatient programs, foods/supplements, and equipment — are not covered; see “Expenses That Are Not Eligible.”
OB/GYN Services: Charges for obstetrical and gynecological services, including treatment and preventive care as indicated in the "Benefit Summary."
Observation Care: Charges for outpatient services typically provided for the purposes of short-term treatment, stabilization, or assessment to facilitate a decision regarding inpatient admission or discharge. Excessive observation care may be determined not to be medically necessary and thus excluded from coverage.
On-Site Clinic Services: Expenses for services and supplies provided by Improve Health Clinics PLLC, to the extent available at your work location. Services may include, but are not limited to:
- Routine examinations and services
- School and sports physical exams (covered only at the on-site clinic)
- Wellness care (immunizations, screenings, etc.)
- Blood pressure exams
- Blood sugar exams
- Tuberculosis skin exams
- First aid for minor injuries
- Ordering lab tests
- Diagnosing and treating health problems
- Writing prescriptions
- Over-the-counter drugs, injections, and supplies that are prescribed for the member by a nurse practitioner or physician
- Video-conference or other telehealth consultations
Coverage for on-site clinic services is offered to provide quality health care, cost savings, and convenience. These services are neither required to be used nor intended to replace your personal choice of health care providers.
Orthopedic Shoes and Attachments: Subject to preauthorization requirements, charges for therapeutic shoes and inserts for members with diabetes mellitus, up to one pair of shoes and three sets of inserts per calendar year. Braces or shoe modifications are covered only if they are a substitute for inserts.
Orthoptic and Pleoptic Training: Charges for orthoptic and pleoptic training, subject to the following limitations:
- Up to 15 visits per calendar year per member
- Covered only with the diagnosis of convergence insufficiency
Orthotic Devices: Charges for a rigid or semi-rigid supportive device, which limits or stops motion of a weak or diseased body part and which is necessary to restore you to your previous level of daily living activity. Benefits for replacement of such devices will be provided only when necessary due to changes in the size of the body part being supported. The following orthotic devices are covered:
- Braces for the leg, arm, neck, back, or shoulder
- Back and special surgical corsets
- Custom orthotic shoe inserts
- Splints for the extremities
- Custom venous compression stockings
Not covered are:
- Arch supports and other foot support devices (except for custom orthotic shoe inserts)
- Garter belts or similar devices
Outpatient Diagnostic Services: Charges for:
- Radiology, ultrasound, and nuclear medicine
- Laboratory and pathology
- ECG, EEG, and other electronic diagnostic medical procedures and physiological medical testing, as determined by the Plan
Imaging (except echocardiography performed in a doctor’s office, X-ray, routine ultrasounds, and venous Doppler ultrasounds) is subject to preauthorization requirements.
Outpatient Therapy Services: Charges for the following services (subject to the limits shown in "Benefit Summary"):
- Radiation therapy
- Chemotherapy (subject to preauthorization requirements)
- Respiratory therapy
- Dialysis (subject to preauthorization requirements)
- Speech therapy
- Physical therapy and occupational therapy
Pregnancy-Related Services: Except as provided below, charges related to the pregnancy of a female employee or the covered wife of a male employee, including:
- Prenatal care (including ultrasounds for a routine pregnancy)
- Routine delivery services
- Complications of pregnancy
- Interruptions of pregnancy due to a health condition affecting the mother or prenatal child
- Care for the newborn child before release from the hospital (subject to preauthorization requirements if the newborn's stay will extend beyond 48 hours following a vaginal delivery, or 96 hours following a cesarean section)
- Postnatal care (subject to preauthorization requirements if the mother's stay will extend beyond 48 hours following a vaginal delivery, or 96 hours following a cesarean section)
Charges related to surrogate parenting or gestational carrier services, including (but not limited to) pregnancy and maternity charges incurred by a member acting as a surrogate parent, are not covered.
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (96 hours). Pregnancy-related hospitalizations other than for childbirth are subject to the usual preauthorization requirements under the Plan.
Except for applicable preventive care services, emergency services, or as otherwise required by applicable law, pregnancy-related services for dependent children — including services for complications of pregnancy — are not covered.
Preventive Care Services: The following items and services, subject to the limitations described below and otherwise in this summary plan description (SPD):
- Evidence-based items or services that have, in effect, a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved;
- Immunizations for routine use in children, adolescents and adults that have, in effect, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;
- With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
- With respect to women, such additional evidence-informed preventive care and screenings as provided for in binding comprehensive health plan coverage guidelines supported by the Health Resources and Services Administration.
For services not exceeding the frequency specified by the above-referenced recommendations and guidelines, the exams or tests are reimbursed at the preventive care benefit level (shown in “Benefit Summary”). If a frequency for the service is not specified by the above-referenced recommendations and guidelines, up to one such service per calendar year is covered at the preventive care benefit level. In both cases, preventive care services exceeding these frequencies are not covered. As noted in "Appendix C: Services and Products that Require Preauthorization," some diagnostic services, such as diagnostic colonoscopies, require preauthorization.
Coverage for preventive care services includes related office visits and services (such as lab tests and X-rays) if not billed separately and if the primary purpose of the visit is the preventive care services. Otherwise, the office visit and related services are subject to the benefit level shown in “Benefit Summary.”
An item or service will be considered a “preventive care service” beginning on the date the Public Health Service Act requires the Plan to cover that item or service.
Information regarding the specific items and services that are covered under the above-referenced recommendations and guidelines is available at healthcare.gov (for preventive services) and cdc.gov (for vaccines); however, certain items and services may be listed on these websites before they are required to be covered by the Plan. The items or services that are “preventive care services” can change from time to time as the recommendations and guidelines are modified. You can receive, without charge, a list of the specific items and services that are “preventive care services” by requesting such list from Member Services.
For information about Approved Preventive Drugs, see the Prescription Drug Plan section.
Prosthetic Appliances: Charges for devices, along with pertinent products, which replace all or part of an absent body organ and which are necessary for the alleviation or correction of conditions arising out of covered bodily injury or illness. Eyeglass lens, soft lens, and contact lens are included if prescribed as part of postoperative treatment for cataract extraction. Implantation or removal of breast prostheses is an eligible expense only in connection with reconstructive breast surgery performed solely and directly as a result of medically necessary mastectomy. As with certain other types of durable medical equipment, prosthetic appliances are subject to preauthorization requirements.
Benefits for replacement appliances will be provided only when necessary due to changes in the size of the limb being augmented.
Reconstructive Surgery: Charges for reconstructive surgery to correct a disfiguring condition caused by an injury or illness, but only to the extent required to return the patient's condition reasonably close to the condition that existed immediately before the injury or illness within a reasonable period of time following the injury or illness. For members receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
- All states of reconstruction of the breast on which the mastectomy was performed,
- Surgery and reconstruction of the other breast to produce a symmetrical appearance,
- Prostheses, and
- Treatment of physical complications of the mastectomy, including lymphedema.
All inpatient admissions are subject to preauthorization requirements.
Rehabilitation or Habilitation Care: Inpatient or outpatient services, including physical therapy, speech therapy, and occupational therapy, provided by the rehabilitation department of a hospital or other Plan-approved rehabilitation facility, after the acute care stage of an illness or injury. A facility providing rehabilitation services must be: (i) licensed to provide such services by the state (or other jurisdiction, if applicable) in which it is operating; and (ii) accredited by a recognized accrediting body (as determined by the Plan Administrator) or, if outside the United States, licensed or approved by the foreign government or an accreditation or licensing body working in that foreign country.
As with all inpatient admissions, care received at an inpatient rehabilitation facility requires preauthorization.
Second Opinion: Charges by an independent physician to provide additional information to help you make treatment decisions. Services may include examination, review of results of any previous diagnostic tests or imaging, additional diagnostic tests or imaging (if medically necessary), and recommendations.
Skilled-Nursing Facility Services: Charges for covered inpatient hospital services and products given to an inpatient of a Plan-approved skilled nursing facility. As with all inpatient admissions, skilled-nursing facility services are subject to preauthorization. No benefits are payable:
- Once you can no longer improve from treatment, or
- For custodial care, or care for someone's convenience.
Special Services: Charges for otherwise excluded services, provided in connection with an individualized plan of care approved by Care Coordination, when it relates to an illness or injury that is expected to require significant or complex health care treatment. The plan of care may include specialized or Non-Direct providers (covered at the Alliance Direct benefit levels) and related travel (subject to the Plan's travel benefit provisions).
Transplants: To be covered by the Plan, all transplants require preauthorization and must be performed in and by a provider that meets the criteria established by the Plan for assessing and selecting providers for transplants. Specialized providers for a particular transplant (covered at the Alliance Direct benefit level) may be available to you by arrangement through Care Coordination in addition to the Plan's Alliance Direct providers. You will be advised of any such option, and you may call Member Services at (855) 979-5192 for more information if you have questions about other providers. Preauthorization must be obtained by you or your provider at the time you are referred for a transplant and/or evaluation. It is your responsibility to make sure preauthorization is obtained. Failure to obtain preauthorization will result in a 100% benefit penalty (in other words, the Plan will not cover any of the transplant expenses). Eligible transplant expenses are described under "Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services."
Vision Care to Treat Certain Illness or Injury: Charges for care of aphakic patients (including lenses required after cataract surgery) and for soft lenses or sclera shells to treat illness or injury; expenses for vision examinations related to the prescription or fitting of lenses are eligible only when performed in connection with the diagnosis or treatment of illness or injury.
Wigs or Other Scalp Prostheses: Wigs or other scalp prostheses necessary for the comfort and dignity of the patient and required due to hair loss resulting from radiation therapy or chemotherapy. Covered expenses are considered an Alliance Direct outpatient service/supply and are limited to $750 per calendar year per member.