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Benefit

Handbook

The Harvard Pilgrim Independence Plansm

For Group Insurance Commission Members

Effective July 1, 2013

This benefit plan is provided to you by the Group Insurance Commission (GIC) on a self-insured basis. Harvard Pilgrim Health Care has arranged for the availability of a network of health care Providers and will be performing various benefit and claim administration and case management services on behalf of the GIC. Although some materials may refer to you as a Member of one of Harvard Pilgrim Health Care’s products, the GIC is the insurer of your coverage.

Effective Date: July 1, 2013

Form No. 461 cc1512/gic/ma 06/13

INTRODUCTION

Welcome to the Harvard Pilgrim Independence Plansm (the Plan). Thank you for choosing this Plan to help you meet your health care needs.

The health care services under this Plan are administered by Harvard Pilgrim Health Care (HPHC) through its Provider network. The Harvard Pilgrim Independence Plan is a self-insured health benefits plan for the Group Insurance Commission (GIC). The GIC is financially responsible for this Plan's health care benefits. HPHC provides benefits, claims administration and case management services on behalf of the GIC as outlined in this Benefit Handbook, Schedule of Benefits and the Prescription Drug Brochure.

Under the Plan, you can use either HPHC’s network of Participating Providers or use Providers of your choice outside of the HPHC network to obtain these services. You have one set of Covered Services under the Plan. If a benefit limit applies, HPHC calculates your utilization for that benefit based on the Covered Services you have received from both Participating Providers and Non-Participating Providers. Although coverage is provided for both types of Providers, services obtained from Participating Providers generally have a lower Member cost.

If you choose to receive Covered Services from a Provider or at a facility that is not a Participating Provider, your benefits will be covered at the Out-of-Network level.

Under this Plan, the GIC provides the covered health care services described in this Benefit Handbook, your Schedule of Benefits and the Prescription Drug Brochure.

Notice: HPHC uses clinical review criteria to evaluate whether certain services or procedures are Medically Necessary for a Member’s care. Members or their practitioners may obtain a copy of any HPHC clinical review criteria that is applicable to a service or procedure for which coverage is requested. Clinical review criteria may be obtained by calling 1-888-888-4742 ext. 38723.

You may call the HPHC Member Services Department if you have any questions. HPHC values your input and would appreciate any comments or suggestions you may have. Member Services staff are available to help you with questions about the following:

Your Benefit Handbook, the Schedule of Benefits, and the Prescription Drug Brochure

Your In-Network and Out-of-Network benefits

Enrollment

Claims

Selecting a Primary Care Provider or a specialist

Requesting a Provider Directory

Requesting a Member kit

Requesting ID cards

Registering a concern

The Member Services Department phone number is
1-888-333-4742. You may also email them at , or write to them at the following address:

Harvard Pilgrim Health Care

Member Services Department

1600 Crown Colony Drive

Quincy, MA 02169

Deaf and hearing-impaired Members who own or have access to a Teletypewriter (TTY) may communicate directly with the Member Services Department by calling HPHC’s TTY machine at 1-800-637-8257.

Non-English speaking Members may also call the HPHC Member Services Department at 1-888-333-4742 with questions. HPHC offers free language interpretation services in more than 120 languages.

TABLE OF CONTENTS

INTRODUCTION 3

Your Benefit Handbook, the Schedule of Benefits, and the Prescription Drug Brochure 3

Your In-Network and Out-of-Network benefits 3

Enrollment 3

Claims 3

Selecting a Primary Care Provider or a specialist 3

Requesting a Provider Directory 3

Requesting a Member kit 3

Requesting ID cards 3

Registering a concern 3

I. BENEFIT HANDBOOK 45

Section A. About the Harvard Pilgrim Independence Plan 45

1. How to use this Benefit Handbook 45

What is covered; 45

What is not covered; 45

Any limits or special rules for coverage; 45

Any Prior Plan Approval or Notification requirements; and 45

Any Member Cost, which means any Copayments, Coinsurance, Deductibles or Benefit Reductions you must pay for the health care services you receive. 45

2. How the Plan Works 45

1-800-708-4414 for Medical Services 46

1-888-777-4742 for Mental Health and Substance Abuse Services 46

Allergy/Immunology, including Pediatric Allergy, and Pediatric Immunology 46

Cardiovascular Disease, including Cardiology (non-interventional), Clinical Cardiac Electrophysiology, and Pediatric Cardiology 46

Dermatology, including Pediatric Dermatology 46

Endocrinology 46

Gastroenterology,
including Pediatric Gastroenterology 46

General Surgery, including Abdominal Surgery, Pediatric Surgery, Peripheral Vascular Surgery, Proctology, Surgery, Colon and Rectal Surgery and Vascular Surgery 46

Neurology, including Clinical Neurophysiology 46

Obstetrics/Gynecology 46

Ophthalmology, including Pediatric Ophthalmology 46

Orthopedics, including Orthopedic Surgery, Hand Surgery and Pediatric Orthopedics 46

Otolaryngology 46

Pulmonology 46

Rheumatology 46

All HPHC Providers (Massachusetts and other states) in: internal, adolescent and geriatric medicine; family and general practice; pediatrics; physical, speech and occupational therapy; chiropractic; audiology; optometry; and midwives and nurse practitioners. These Providers have a $20 Copayment. 47

Massachusetts physicians in the 13 tiered specialties for whom there was insufficient data to measure. These specialists have the same Copayment as Tier 2 specialists. 47

Some providers work from offices that are operated by a hospital. When services are rendered and billed from such an office, a $35 Copayment will be applied. However, please contact HPHC Member Services if you received care from a physician who specializes in internal, adolescent or geriatric medicine; family and general practice; pediatrics; or a midwife or a nurse practitioner in such an office to determine if you are subject to a $20 copayment. 47

Non-Massachusetts physicians in the 13 tiered specialties. These specialists have the same Copayment as Tier 2 specialists. 47

All other HPHC specialists (Massachusetts and other states) outside of the 13 tiered specialties. These physicians have the same Copayment as Tier 2 specialists. 47

Hospitals that met the quality threshold and had lower costs were placed in Tier 1. 47

Hospitals that had mid-range costs, regardless of whether they met the quality threshold, were placed in Tier 2. 47

Hospitals that did not meet the quality threshold but had lower costs were placed in Tier 2. 47

Hospitals that had higher costs, regardless of whether they met the quality threshold, were placed in Tier 3. 47

Heart attack or suspected heart attack 48

Stroke 48

Shock 48

Major blood loss 48

Choking 48

Severe head trauma 48

Loss of consciousness 48

Seizures 48

Convulsions 48

3. How Your In-Network Coverage Works 48

Internal, Adolescent and Geriatric Medicine 48

Family and General Practice 48

Pediatrics 48

Physical, Speech and Occupational Therapy 48

Chiropractic 48

Audiology 49

Optometry 49

Midwives, Nurse Practitioners and
Physician Assistants 49

Massachusetts physicians in the 13 tiered specialties for whom there was insufficient data to measure. 49

Some providers work from offices that are operated by a hospital. When services are rendered and billed from such an office, a $35 Copayment usually applies. However, please contact HPHC Member Services if you received care from a physician who specializes in internal, adolescent or geriatric medicine; family and general practice; pediatrics; or a midwife, nurse practitioner or a physician assistant in such an office to determine if you are subject to a $20 copayment. 49

Non-Massachusetts physicians in the 13 tiered specialties. 49

All other HPHC specialists (Massachusetts and other states) outside of the 13 tiered specialties. 49

Hospital Tier 1 copayment is $250 49

Hospital Tier 2 copayment is $500 49

Hospital Tier 3 copayment is $750 49

Some laboratory tests 49

Radiology (for example, X-Rays; MRI, CT, and PET scans) 49

Emergency room services (at both In-Network and Out-of-Network hospitals) 50

Outpatient surgery 50

Inpatient admissions 50

Applied Behavior Analysis 50

Mammograms 50

Mental Health/Substance Abuse admissions 50

Office Visits. However, certain ancillary tests and procedures performed at an office visit may be subject to the Deductible 50

Preventive Care Services (as specified by the Patient Protection and Affordable Care Act), including routine physical examinations and certain tests when they are provided by a HPHC network provider (see page 58). See “Routine Physical Examinations” for details. 50

Routine outpatient prenatal and post-partum care and routine nursery charges for a healthy newborn provided by a HPHC network provider. However, certain ancillary tests and procedures performed at an office visit may be subject to the Deductible. 50

Speech Therapy 50

Wigs 50

Accept reimbursement from the Plan at the rates applicable prior to notice of disenrollment as payment in full and not to impose cost sharing with respect to the Member in an amount that would exceed the cost sharing that could have been imposed if the Provider had not been disenrolled; 50

Adhere to the quality assurance standards of HPHC and to provide the Plan with necessary medical information related to the care provided; and 51

Adhere to the Plan’s policies and procedures, obtaining Prior Plan Approval and providing Covered Services pursuant to a treatment plan, if any, approved by the Plan. 51

4. How Your Out-of-Network
Coverage Works 51

Outpatient emergency room services 51

Benefit Reductions 51

Hearing aids 51

Copayments 51

Skilled nursing facility Coinsurance 51

Prescription drug Copayments 51

Benefit Reductions 51

Any charges in excess of the Allowed Amount. 51

5. Out-of-Area Covered Services
from our affiliated national network of providers 52

6. Prior Approval Program 52

1-800-708-4414 for Medical Services 52

1-888-777-4742 for Mental Health and Substance Abuse Services 52

Blepharoplasty - plastic surgery on an eyelid especially to remove fatty or excess tissue. This procedure is sometimes done in conjunction with Ptosis repair when the excess tissue is due to a medical disease. 52

Bone marrow transplant/stem cell transplant 52

Breast implant removal 52

Breast reduction surgery (mammoplasty) 52

Gynecomastia surgery 52

Weight loss surgery (bariatric surgery) 52

Intravenous Immunoglobulin (IVIg) 52

Laminectomy/Discectomy – procedures done on the vertebra in the back usually for disc disease 52

Mandibular/Maxillary osteotomy – surgical procedures to realign the jaw, usually for patients with obstructive sleep apnea 52

Medical treatment of temporomandibular joint (TMD) treatment 52

Odontectomy - the removal of teeth by the reflection of a mucoperiosteal flap and excision of bone from around the root or roots before the application of force to effect the tooth removal 53

Panniculectomy - a procedure to remove fatty tissue and excess skin from the lower to middle portions of the abdomen 53

Port wine stain laser treatment 53

Ptosis repair - a procedure to repair the sagging or a drooping of the upper eyelid such that the drooping eyelid impairs the vision as measured by a visual field test 53

Reconstructive surgery and procedures (includes scar revision and other potential cosmetic services) 53

Rhinoplasty – plastic surgery to change the shape or size of the nose 53

Septoplasty – surgical procedure to correct defects or deformities of the nasal septum 53

Uvulopalatopharyngoplasty (UPPP) - a surgical procedure to remove excess soft tissue surrounding the uvula, soft palate, and tonsils to create a wider opening in the back of the mouth to treat sleep apnea 53

Varicose vein excision and ligation 53

Durable medical equipment – Continuous glucose monitoring systems only 53

Infertility services – Including but not limited to advanced reproductive technology (ART): in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), intra-cytoplasmic sperm injection (ICSI) and donor egg procedures. 53

Home health care, including home infusion and home hospice 53

Infant formula 53

Inpatient and Surgical Day Care dental care, extractions and oral or periodontal surgery 53

Inpatient rehabilitation care, including inpatient pulmonary rehabilitation 53

Inpatient skilled nursing care (SNF) 53

Intra-facility admissions (transfers) 53

Inpatient Mental Health and Substance Abuse services 53

Outpatient enteral nutrition 53

Outpatient Mental Health Care Services (including the treatment of substance abuse disorders) - Intensive outpatient program treatment (treatment programs at an outpatient clinic or other facility generally lasting three or more hours a day on two or more days a week), partial hospitalization and day treatment programs, extended outpatient treatment visits (outpatient visits of more than 50 minutes duration with or without medication management or any treatment routinely involving more than one outpatient visit in a day), outpatient electro-convulsive treatment (ECT), psychological testing and neuro-psychological assessment, and applied behavior analysis (ABA) for the treatment of autism. 53

Outpatient pulmonary rehabilitation 53

Radiology – outpatient advanced technologies: computerized axial tomorgraphy (CAAT CT, and CTA scans), magnetic resonance imaging (MRI and MRA scans), nuclear cardiac studies, and positron emission tomography (PET scans). 53

Speech/language therapy 53

For medical services, call 1-800-708-4414 54

For all mental health and substance abuse services, call 1-888-777-4742 54

The Member's name 54

The Member's ID number 54

The treating Provider's name, address and telephone number 54

The diagnosis for which care is ordered 54

The treatment ordered and the date it is expected to be performed 54

The name and address of the facility where care will be received 54

The admitting Provider's name, address and telephone number 54

The admitting diagnoses and date of admission 54

The name of any procedure to be performed and the date it is expected to be performed 54

If Prior Plan Approval is not obtained, you will not be covered if the Plan determines the procedure or service was not Medically Necessary. 54

If Prior Plan Approval is not obtained, but it is determined that the procedure or service is Medically Necessary, the procedure or service will be subject to Benefit Reductions, before the Plan begins coverage for the service. The Benefit Reductions amount is not applied to the Deductible or Out-of-Pocket Maximum. 54

7. Notification 54

All medical admissions to an inpatient facility, (including admissions for maternity care) except for those procedures or services previously noted in the Prior Plan Approval section. 54

All Surgical Day Care Services, except for those procedures or services previously noted in the Prior Plan Approval section 54

Human organ transplants, except for bone marrow or stem cell transplants (see Prior Plan Approval) 55

Outpatient physical and occupational therapy services 55

8. When You Receive In-Network
and Out-of-Network Coverage
for the Same Condition 55

9. Centers of Excellence 55

Weight loss surgery (bariatric surgery) 55

Section B. COVERED SERVICES 56

1. Basic Requirements for Coverage 56

Medically Necessary; 56

Received while a Member of the Plan; 56

Listed in Section B. on pages 56-78, “Covered Services” and not excluded in Section I.B.9. on pages 81-82, “Exclusions.” 56

2. Inpatient Care 56

Semi-private room and board 56

Doctor visits, including consultation with specialists 56

Medications 56

Lab and x-ray services 56

Intensive care 56

Surgery, including related services 56

Anesthesia, including the services of a nurse-anesthetist 56

Radiation therapy 56

Physical therapy, occupational therapy and speech therapy 56

If you are admitted from March 2 until March 7, you are responsible for an Inpatient Copayment. If you are then readmitted from March 12 until March 15, the second Inpatient Copayment is waived because it is within the same Quarter as the first admission. 56

If you are admitted March 2 until March 7, and then readmitted April 3 until April 8, the second Inpatient Copayment is waived even though it is a new Quarter because it is within 30 calendar days of the original discharge. 56

If you are admitted March 2 until March 7, and then readmitted April 30 until May 2, you are responsible for the second Inpatient Copayment. The second admission occurred more than 30 days from the original discharge and it is a new Quarter. 56

If you are admitted December 2 until December 7, and then readmitted January 1 until January 4, you are responsible for the second Inpatient Copayment. Although the second admission occurred less than 30 days from the original discharge, and it is a new calendar year. 56

If you are using a Participating Provider, (s)he will arrange the admission and provide Notification or obtain Prior Plan Approval, whichever is appropriate. 57

If you are using a Non-Participating Provider, you are responsible for providing Notification or obtaining Prior Plan Approval, whichever is appropriate, by calling: 1-800-708-4414. 57

Weight loss surgery (bariatric surgery) 57

In-Network: Member pays the Acute Hospital Inpatient Copayment once per Quarter, then the In-Network Deductible 57

Out-of-Network: Member pays 20% after the Out-of-Network Deductible up to the Out-of-Network Out-of-Pocket Maximum, and any balance above the Allowed Amount 57

If you are using a Participating Provider, (s)he will arrange the admission and obtain Prior Plan Approval. 57

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 57

In-Network: Member pays 20% Coinsurance of the Allowed Amount, after the In-Network Deductible. 57

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. Member Cost for skilled nursing facility services does not apply to the Out-of-Network Out-of-Pocket Maximum. 57

If you are using a Participating Provider, (s)he will arrange the admission and obtain Prior Plan Approval. 57

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 57

In-Network: Covered in Full, after the In-Network Deductible. 57

Out-of-Network: Member pays 20% after Out-of-Network the Deductible, up to the Out-of-Network Out-of-Pocket Maximum and any balance above the Allowed Amount. 57

Personal items, including telephone and television charges 57

All charges over the semi-private room rate, except when a private room is Medically Necessary 58

Rest or Custodial Care 58

Blood or blood products 58

Charges after your Hospital discharge 58

Charges after the date on which your membership ends 58

3. Outpatient Care 58

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 58

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 58

In-Network: Member pays a $100 Copayment per ER visit, then the In-Network Deductible. This Copayment is waived if you are admitted directly from the emergency room, in which case you will be responsible for the Inpatient Acute Hospital Copayment. 58

Out-of-Network: Member pays a $100 Copayment per ER visit, then the In-Network Deductible. This Copayment is waived if you are admitted directly from the emergency room, in which case you will be responsible for the Inpatient Acute Hospital Copayment. 58

In-Network: Member pays a $150 Surgical Day Care Copayment, then the In-Network Deductible. 58

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 58

In-Network: Covered in full. 58

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 58

Exams and testing that are not part of a routine physical exam, including school, sports, camp, insurance, licensing, premarital, and employment exams 58

Abdominal aortic aneurysm screening (for males 65-75 one time only, if ever smoked) 58

Alcohol misuse screening and counseling (primary care visits only) 58

Aspirin for the prevention of heart disease (primary care counseling only) 58

Autism screening (for children at 18 and 24 months of age, primary care visits only) 59

Behavioral assessments (children of all ages; developmental surveillance, in primary care settings) 59

Blood pressure screening (adults, without known hypertension) Breast cancer chemoprevention (counseling only for women at high risk for breast cancer and low risk for adverse effects of chemoprevention) 59

Cervical cancer screening, including pap smears 59

Cholesterol screening (for adults only) 59

Colorectal cancer screening, including colonoscopy, sigmoidoscopy and fecal occult blood test 59

Dental caries prevention - oral fluoride (for children to age 5 only) 59

Depression screening (adults, children ages 12-18, primary care visits only) 59

Diabetes screenings 59

Diet behavioral counseling (included as part of annual visit and intensive counseling by primary care clinicians or by nutritionists and dieticians) 59

Dyslipidemia screening (for children at high risk for higher lipid levels) 59

Folic acid supplements (women planning or capable of pregnancy only) 59

Hemoglobin A1c tests for Members who are diabetic 59

Hepatitis B testing 59

HIV screening 59

Immunizations, including flu shots (for children and adults as appropriate) 59

Iron deficiency prevention (primary care counseling for children age 6 to 12 months only) 59

Lead screening (children at risk) 59

Microalbuminuria test 59

Obesity screening (adults and children screening only, in primary care settings) 59

Osteoporosis screening (screening to begin at age 60 for women at increased risk 59

Ovarian cancer susceptibility screening 59

Sexually transmitted diseases (STDs) – screenings and counseling 59

Tobacco use counseling (primary care visits only) 59

Total cholesterol tests 59

Tuberculosis skin testing 59

Vision screening (children to age 5 only) 59

In-Network: Covered in full. 59

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 59

In-Network: If you see an optometrist, $20 copayment. 60

If you see an ophthalmologist, No Member Cost after the applicable Copayment: 60

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 60

In-Network: No Member Cost after the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 60

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 60

In-Network: Member pays a $100 Copayment per emergency room visit, then the In-Network Deductible. This Copayment is waived if you are admitted directly from the emergency room, in which case you will be responsible for the Inpatient Acute Hospital Copayment. You are responsible for a maximum of one Inpatient Copayment each Quarter in a calendar year. 60

Out-of-Network: Member pays a $100 Copayment per ER visit, then the In-Network Deductible. This Copayment is waived if you are admitted directly from the emergency room, in which case you will be responsible for the Inpatient Acute Hospital Copayment. 60

In-Network: Covered in Full, after the In-Network Deductible. 60

For cost-sharing for preventive services and tests see “Routine Physical Examinations.” 60

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 60

If you are using a Participating Provider, (s)he will arrange the services and provide Notification. 61

If you are using a Non-Participating Provider, you are responsible for providing Notification by calling 1-800-708-4414. 61

In-Network: Member pays a $20 Copayment
per visit. 61

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 61

Educational services or testing, except services covered under the benefit for Early Intervention Services 61

Sensory integrative praxis tests 61

Vocational rehabilitation, or vocational evaluations focused on job adaptability, job placement, or therapy to restore function for a specific occupation 61

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 61

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 61

In-Network: No Member Cost. 61

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 61

Educational services or testing, except services covered under the benefit for Early Intervention Services, in Section I.B.3.g. below 61

Services for problems of school performance 61

Sensory integrative praxis tests 61

Vocational rehabilitation, or vocational evaluations focused on job adaptability, job placement, or therapy to restore function for a specific occupation 61

Screening and assessment of the need for services 61

Physical, speech, and occupational therapy 61

Psychological counseling 61

Nursing care 61

In-Network: Member pays a $20 Tier 1 Copayment per visit. 61

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 61

If you are using a Participating Provider, (s)he will arrange the admission and provide Notification or obtain Prior Plan Approval, whichever is appropriate. 62

If you are using a Non-Participating Provider, you are responsible for providing Notification or obtaining Prior Plan Approval, whichever is appropriate, by calling: 1-800-708-4414. 62

In-Network: Member pays a $150 Surgical Day Care Copayment, then the In-Network Deductible. 62

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 62

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49). 62

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 62

In-Network: There is no Member Cost for office visits when only the administration of an allergy injection is provided. Otherwise, the Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49). 62

Tier 1 Copayment: $20 per office visit 62

Tier 2 Copayment: $35 per office visit 62

Tier 3 Copayment: $45 per office visit 62

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 62

If you are using a Participating Provider, (s)he will arrange the services and provide Notification or obtain Prior Plan Approval, whichever is appropriate. 62

If you are using a Non-Participating Provider, you are responsible for providing Notification or obtaining Prior Plan Approval, whichever is appropriate, by calling: 1-800-708-4414. 62

Please see the list in Sections I.A.6. and I.A.7., on pages 52-54, for details regarding which services require Prior Plan Approval and Notification. 62

In-Network: Member pays $100 Copayment per scan, then the In-Network Deductible, maximum of one Copayment per Member per day. 62

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 62

4. Family Planning Services
and Infertility Treatment 63

Annual gynecological examination 63

Family planning consultation 63

Pregnancy testing 63

Voluntary sterilization, including tubal ligation. 63

Voluntary termination of pregnancy 63

Contraceptive monitoring by a Provider (including but not limited to checking, reinserting, or removing a contraceptive device) 63

Genetic counseling 63

Vasectomy 63

In-Network: Annual gynecological examinations are covered in full. 63

No Member charge for contraceptive devices or injections provided during an office visit. 63

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 63

In-Network: Member pays a $150 Surgical Day Care Copayment, then the In-Network Deductible. 63

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 63

Reversal of voluntary sterilization 63

Consultation and evaluation 63

Laboratory tests 63

Artificial insemination (AI), including related sperm procurement and banking 63

The Plan also covers up to a total of five cycles of advanced reproductive technologies (ART) when Medically Necessary. Advanced reproductive technologies includes in-vitro fertilization including embryo placement (IVF-EP), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), intra-cytoplasmic sperm injection (ICSI), and donor egg procedures, including related egg and inseminated egg procurement, processing and banking 63

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 63

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 63

In-Network: No Member Cost after the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 63

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 64

In-Network: Member pays a $150 Surgical Day Care Copayment, then the In-Network Deductible. 64

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 64

Reversal of voluntary sterilization 64

Any infertility treatment related to voluntary sterilization or its reversal 64

Infertility treatment for Members who are not medically infertile 64

Any form of surrogacy 64

5. Maternity Care 64

Outpatient prenatal and post-partum care, including counseling about alcohol and tobacco use, services to promote breastfeeding, routine urinalysis and screenings for the following: asymptomatic bacteriuria; hepatitis B infection; HIV and screenings for STDs (chlamydia, gonorrhea and syphilis); iron deficiency anemia; and Rh (D) incompatibility. 64

Diagnostic tests 64

Diet regulation 64

Pre-natal genetic testing 64

Delivery, including a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a cesarean section. Any decision to shorten the inpatient stay for the mother and her newborn child will be made by the attending physician and the mother. If the inpatient stay is less than 48 hours (or 96 hours in the case of a cesarean delivery) the Plan will cover at least one home visit by a registered nurse or certified nurse midwife. 64

Nursery charges for routine services provided to a healthy newborn, including prophylactic medication to prevent gonorrhea and screenings for the following: hearing loss; congenital hypothyroidism; phenylketonuria (PKU); and sickle cell disease. 64

Non-routine prenatal and post-partum care, including, but not limited to: 64

Administration and supply of immune globulin, RhoGAM 64

Amniocentesis 64

Nuchal translucency ultrasound when performed separately from a standard obstetrical ultrasound 64

Non-routine nursery charges for a newborn (covered as a separate inpatient stay) 64

If you are using a Participating Provider, (s)he will arrange the admission and provide Notification. 64

If you are using a Non-Participating Provider, you are responsible for providing Notification by calling 1-800-708-4414. 64

In-Network: No Member Cost for routine outpatient prenatal and post-partum care, after the In-Network Deductible, where applicable (see page 49). 64

Non-routine outpatient prenatal and post-partum care are subject to applicable Member cost sharing. 64

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 64

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 64

Routine nursery charges for a healthy newborn are covered in full. 64

Non-routine nursery charges for a newborn are covered as a separate inpatient stay, and are subject to the Inpatient Acute Hospital Copayment, then the In-Network Deductible 64

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 64

Services for a newborn who has not been enrolled as a Member, other than nursery charges for routine services provided to a healthy newborn 65

Planned home births 65

6. Mental Health and
Substance Abuse Services 65

When receiving Out-of-Network services, there are certain outpatient mental health care services (including the treatment of substance abuse disorders) for which you must obtain Prior Plan Approval. Please see section I.B.6.b. “Outpatient Services - Mental Health and Substance Abuse Services” for additional information. The Prior Approval process is initiated by calling: 1-888-777-4742. Further information about Prior Plan Approval may be found in Section I.A.6. on page 52. 65

In-network: None 65

Out-of-Network: $400 per Member, $800 per Family 65

In-Network: $1,000 per Member, $2,000 per Family 65

Out-of-Network: $3,000 per Member per calendar year, for medical and mental health and substance abuse services. 65

In-Network: None 65

Out-of-Network: $200 applied to any service that requires Prior Plan Approval if such Prior Plan Approval is not received. 65

Inpatient mental health care is covered when it is Medically Necessary. 65

Services are covered in a general or psychiatric Hospital without day limits. 65

Inpatient rehabilitative care for substance abuse is covered when it is Medically Necessary. 65

Services are covered in a general Hospital or substance abuse facility without day limits. 65

Inpatient detoxification is covered as long as it is Medically Necessary. 65

If you are admitted from March 2 until March 7, you are responsible for an Inpatient Copayment. If you are then readmitted from March 12 until March 15, the second Inpatient Copayment is waived because it is within the same Quarter as the first admission. 65

If you are admitted March 2 until March 7, and then readmitted April 3 until April 8, the second Inpatient Copayment is waived even though it is a new Quarter because it is within 30 calendar days of the original discharge. 65

If you are admitted March 2 until March 7, and then readmitted April 30 until May 2, you are responsible for the second Inpatient Copayment. The second admission occurred more than 30 days from the original discharge and it is a new Quarter. 65

If you are admitted December 2 until December 7, and then readmitted January 1 until January 4, you are responsible for the second Inpatient Copayment. Although the second admission occurred less than 30 days from the original discharge, it is a new Quarter, and it is a new calendar year. 66

In-Network: Member pays a $200 Hospital Inpatient Copayment per admission, up to a maximum of one Medical and/or Mental Health and Substance Abuse Hospital Inpatient Copayment per Member per Quarter in a calendar year, waived if readmitted within 30 days in the same calendar year. 66

Out-of-Network: None 66

In-Network: None 66

Out-of-Network: Member pays 20% after the Deductible and Hospital Inpatient Copayment, and any balance above the Allowed Amount. 66

Intensive outpatient program treatment (treatment programs at an outpatient clinic or other facility generally lasting three or more hours a day on two or more days a week). 66

Partial hospitalization and day treatment programs. 66

Extended outpatient treatment visits (outpatient visits of more than 50 minutes duration with or without medication management or any treatment routinely involving more than one outpatient visit in a day). 66

Outpatient Electro-Convulsive Treatment (ECT). 66

Psychological testing and neuropsychological assessment. 66

Applied Behavior Analysis (ABA) for the treatment of autism. 66

In-Network: 66

Individual therapy visits: Member pays a $20 Copayment. 66

Group therapy visits: Member pays a $15 Copayment. 66

Out of network: 66

Individual or Group therapy: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 66

In-Network: No Member Cost. 66

Out of network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 66

Educational services or testing, except services covered under the benefit for Early Intervention Services 66

Mental health services that are (1) provided to Members who are confined or committed to a jail, house of correction, prison, or custodial facility of the Department of Youth Services or (2) provided by the Department of Mental Health. 66

In-Network: Member pays a $15 Copayment per visit. 67

Out of Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 67

In-Network: No Member Cost. 67

Out of Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 67

Educational services or testing, except services covered under the benefit for Early Intervention Services 67

Sensory integrative praxis tests 67

7. Dental Services 67

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 67

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 67

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 67

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 67

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 67

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 67

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 67

If you are using a Non-Participating Provider , you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 67

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 68

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 68

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 68

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 68

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 68

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 68

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 68

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 68

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 68

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 68

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 68

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 68

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 68

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 68

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 68

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 68

Initial first aid (trauma care) 68

Reduction of swelling 68

Pain relief 68

Covered non-dental surgery 68

Non-dental diagnostic x-rays 68

Extraction of teeth needed to avoid infection of teeth damaged in the injury 68

Suturing and suture removal 68

Re-implanting and stabilization of dislodged teeth 68

Re-positioning and stabilization of partly dislodged teeth 68

Medication received from the Provider 69

Fillings 69

Crowns 69

Gum care, including gum surgery 69

Braces 69

Root canals 69

Bridges 69

Dentures 69

Bonding 69

In-Network: Member pays a $35 Copayment per visit, then the In-Network Deductible, where applicable (see page 49). 69

Out-of-network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 69

In-Network: Member pays the Emergency Room Copayment, then the In-Network Deductible. 69

Out-of-network: Member pays the Emergency Room Copayment, then the In-Network Deductible. 69

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 69

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 69

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the Deductible. 69

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 69

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 69

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 69

In-Network: Member pays a $35 Copayment per visit, then the In-Network Deductible, where applicable (see page 49). 69

Out-of-network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 69

In-Network: Member pays the Emergency Room Copayment, then the In-Network Deductible. 69

Out-of-network: Member pays the Emergency Room Copayment, then the In-Network Deductible. 69

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 69

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 69

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 69

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 70

Fillings 70

Crowns 70

Gum care, including gum surgery 70

Braces 70

Root canals 70

Bridges 70

Dentures 70

Bonding 70

8. Other Services 70

Skilled nursing care 70

Physical therapy 70

Occupational therapy 70

Speech therapy 70

Medical social services 70

Nutritional counseling 70

Services of a home health aide 70

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 70

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 70

In-Network: Covered in Full, after the Deductible. 70

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 70

Home health care extending beyond a short-term intermittent basis, as previously described 70

Private duty nursing 70

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 71

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 71

In-Network: Covered in Full, after the Deductible for inpatient or outpatient hospice care. Member pays the Acute Hospital Inpatient Copayment for acute inpatient services. 71

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 71

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 71

Tier 1 Copayment: $20 per visit 71

Tier 2 Copayment: $35 per visit 71

Tier 3 Copayment: $45 per visit 71

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 71

The least costly equipment or prosthesis, excluding prosthetic arms and legs, adequate to allow you to do Activities of Daily Living; 71

Prosthetic arms and legs which are the most cost- effective model that adequately meets the Member’s medical needs in the performance of Activities of Daily Living; and 71

One item of each type of equipment that meets the Member's need. No back-up items or items that serve duplicate purposes are covered. For example, the Plan covers a manual or an electric wheelchair, not both. 71

Able to withstand repeated use 71

Not generally useful in the absence of disease or injury 71

Suitable for home use 71

Normally used in the treatment of an illness or injury or for the rehabilitation of an abnormal body part. (This does not apply to prostheses.) 71

Respiratory equipment 71

Certain types of braces 71

Oxygen and oxygen equipment 71

Hospital beds 71

Wheelchairs 71

Walkers 71

Crutches 71

Canes 71

Insulin pumps and blood glucose monitors, including voice-synthesizers and visual magnifying aids when Medically Necessary for their use 71

Continuous glucose monitoring systems (Please Note: Prior Plan Approval is necessary. If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval for continuous glucose monitoring systems (see page 52) by calling 1-800-708-4414.) 71

Prosthetic arms and legs 72

Artificial eyes 72

Breast prostheses, including replacements and mastectomy bras 72

Ostomy supplies 72

Wigs, up to $350 per Member per calendar year when needed as a result of any form of cancer or leukemia, alopecia areata, alopecia totalis, or permanent hair loss due to injury 72

Therapeutic molded shoes, and foot orthotics needed to prevent or treat complications of diabetes 72

In-Network: Covered in Full, after the In-Network Deductible (please note that wigs are not subject to the Deductible). 72

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 72

Exercise equipment 72

Therapeutic molded shoes and foot orthotics, except for members with severe diabetic foot disease 72

Dentures, orthodontics, and appliances to treat temporomandibular joint dysfunction (TMD) disorders 72

Repair or replacement of equipment or devices as a result of loss, negligence, willful damage, or theft 72

Any devices or special equipment needed for sports or occupational purposes 72

Any home adaptations, including, but not limited to, home improvements and home adaptation equipment 72

Any type of thermal therapy device 72

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 72

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval for non-emergency ambulance transport by calling 1-800-708-4414. 72

In-Network: Covered in Full, after the In-Network Deductible. 72

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 72

In-Network: Covered in Full, after the In-Network Deductible. 72

Out-of-Network: Covered in Full, after the In-Network Deductible. 72

If you are using a Participating Provider, (s)he will arrange the services and provide Notification or obtain Prior Plan Approval, whichever is appropriate. 73

If you are using a Non-Participating Provider, you are responsible for providing Notification or obtaining Prior Plan Approval, whichever is appropriate, by calling: 1-800-708-4414. 73

Please see the list in Sections I.A.6. and I.A.7., on pages 52-54, for details regarding which services require Prior Plan Approval and Notification. 73

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 73

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 73

In-Network: Member pays the Surgical Day Care Copayment, then the In-Network Deductible. 73

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 73

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 73

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 73

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 73

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval for services (see page 52) by calling 1-800-708-4414. 73

In-Network: Covered in Full, after the In-Network Deductible. 73

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 73

Care for the recipient 73

Donor search costs through established organ donor registries 73

Donor costs that are not covered by the donor's health plan 74

If you are using a Participating Provider, (s)he will arrange the services you need and provide Notification or obtain Prior Plan Approval, whichever is appropriate. 74

If you are using a Non-Participating Provider, you are responsible for providing Notification or obtaining Prior Plan Approval, whichever is appropriate, by calling: 1-800-708-4414. 74

Please see the list in Sections I.A.6. and I.A.7., pages 52-54, for details regarding which services require Prior Plan Approval or Notification. 74

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 74

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 74

In-Network: Member pays a $150 Surgical Day Care Copayment per admission, then the In-Network Deductible. 74

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 74

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 74

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 74

Human organ or bone marrow transplants that are Experimental or Unproven 74

Special infant formulas, including those formulas approved by the Massachusetts Department of Public Health 74

Formulas for the treatment of malabsorption caused by Crohn’s disease, ulcerative colitis, gastroesophogeal reflux, gastrointestinal motility, or chronic intestinal pseudo-obstruction 74

Low protein foods for inherited diseases of amino and organic acids up to $5,000 per Member per calendar year. 74

If you are using a Participating Provider, (s)he will provide or arrange. 74

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling: 1-800-708-4414. 74

In-Network: Covered in Full, after the In-Network Deductible. 74

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 74

In-Network: Covered in Full, after the In-Network Deductible. 74

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 74

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 75

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval for continuous glucose monitoring systems (see page 52) by calling 1-800-708-4414. 75

In-Network: Covered in Full, after the In-Network Deductible. 75

Out-of-Network: Covered in Full, after the Out-of-Network Deductible. 75

Please see the Prescription Drug Brochure included in this booklet. Your prescription drug Copayments are also listed on your ID Card. 75

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 75

Tier 1 Copayment: $20 per office visit 75

Tier 2 Copayment: $35 per office visit 75

Tier 3 Copayment: $45 per office visit 75

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 75

In-Network: Member pays 10% Coinsurance after the In-Network Deductible 75

Out-of-Network: Not Covered 75

Initial consultation 75

X-rays 75

Physical therapy, subject to the Plan’s limit for outpatient physical therapy 75

Surgery 75

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 75

If you are using a Non-Participating Provider, you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 75

In-Network: Member pays the applicable Copayment, then the In-Network Deductible, where applicable (see page 49) 75

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 75

In-Network: Member pays the Surgical Day Care Copayment per admission, then the In-Network Deductible. 75

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 76

In-Network: Member pays the Inpatient Acute Hospital Copayment, then the In-Network Deductible. 76

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 76

All services of a dentist for Temporomandibular Joint Dysfunction (TMD), except oral surgery 76

Initial diagnostic x-ray 76

Care within the scope of standard chiropractic practice 76

In-Network: Member pays a $20 Copayment per visit, then the In-Network Deductible, where applicable (see page 49). 76

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 76

Care outside the scope of standard chiropractic practice, including but not limited to, surgery, prescription or dispensing of drugs or medications, internal examinations, obstetrical practice, treatment of infectious disease, or treatment with crystals 76

Diagnostic testing other than an initial x-ray 76

In-Network: Covered in Full, after the In-Network Deductible up to the benefit limits described above. 77

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount, up to the applicable benefit limits described above. 77

In-Network: Covered in Full, up to $2,000 per hearing aid every 36 months, for each hearing impaired ear. 77

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 77

In-Network: Covered in Full, for the first $500, then 20% Coinsurance of the next $1,500, up to a maximum benefit of $1,700 every 2 calendar years. 77

Out-of-Network: Covered in Full, for the first $500, then 20% Coinsurance of the next $1,500, up to a maximum benefit of $1,700 every 2 calendar years. 77

Hearing aid batteries, and any device used by individuals with hearing impairment to communicate over the telephone or internet, such as TTY or TDD. 77

No back-up, or spare, hearing aids will be covered. 77

In-Network: Member pays the applicable Copayment 77

Tier 1 Copayment: $20 per office visit 78

Tier 2 Copayment: $35 per office visit 78

Tier 3 Copayment: $45 per office visit 78

Out-of-network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 78

See Member Costs associated with the Patient Care Services being rendered pursuant to the Qualified Clinical Trial. 78

An investigational drug or device. However, a drug or device that has been approved for use in the Qualified Clinical Trial will be a patient care service to the extent that the drug or device is not paid for by the manufacturer, distributor or Provider of the drug or device, regardless whether the Food and Drug Administration has approved the drug or device for use in treating the patient’s particular condition 78

Non-health care services that a patient may be required to receive as a result of participation in the clinical trial 78

Costs associated with managing the research of the clinical trial 78

Costs that would not be covered for non-investigational treatments 78

Any item, service or cost that is reimbursed or furnished by the sponsor of the clinical trial 78

The costs of services that are inconsistent with widely accepted and established national or regional standards of care 78

The costs of services that are provided primarily to meet the needs of the trial, including, but not limited to, tests, measurements and other services that are typically covered but are being provided at a greater frequency, intensity or duration 78

Services or costs that are not covered under the Plan 78

Retail Pharmacy: Member pays the following Copayments for up to a 30-day supply: 78

Mail Order Pharmacy: Member pays the following Copayments for a 90-day supply: 78

Diagnosis of Autism Spectrum Disorders. This includes Medically Necessary assessments, evaluations, including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the Autism Spectrum Disorders. 79

Professional services by Plan Providers. This includes care by physicians, Licensed Mental Health Professionals, speech therapists, occupational therapists, and physical therapists. 79

Habilitative and rehabilitative care, including, but not limited to, applied behavior analysis supervised by a board certified behavior analyst as defined by law. 79

Prescription drug coverage (Please see your Prescription Drug Brochure for information on this benefit). 79

In-Network: Your Member cost sharing depends upon the type of service provided, as listed in the Schedule of Benefits. For example: For services by a Licensed Mental Health Professional see “Mental Health Care (Including the Treatment of Substance Abuse Disorders).” For services by a speech therapist see “Speech, Language and Hearing Services”. For services by a physical therapist and occupational therapist, see “Physical and Occupational Therapies.” 79

Out-of-Network: Your Member cost sharing depends upon the type of service provided, as listed in the Schedule of Benefits. For example: For services by a Licensed Mental Health Professional see “Mental Health Care (Including the Treatment of Substance Abuse Disorders).” For services by a speech therapist see “Speech, Language and Hearing Services”. For services by a physical therapist and occupational therapist, see “Physical and Occupational Therapies.” 79

If you are using a Participating Provider, (s)he will arrange the services and obtain Prior Plan Approval. 79

If you are using a Non-Participating Provider , you are responsible for obtaining Prior Plan Approval by calling 1-800-708-4414. 79

In-Network: Tier 1 Copayment: $20 per office visit 79

Out-of-Network: Member pays 20% after the Out-of-Network Deductible, and any balance above the Allowed Amount. 79

Telephonic or face-to-face counseling. Face-to-face counseling may be completed in either individual or group sessions. 80

FDA-approved prescription medications for the treatment of smoking cessation, with limitations. Please visit for information on your coverage for prescription drugs for smoking cessation. 80

In-Network: Covered in Full. 80

Out-of-Network: Member pays 20% after the Deductible, and any balance above the Allowed Amount. 80

9. Exclusions 81

A provider’s charge to file a claim or to transcribe or copy your medical records 81

A service, supply, or medication if there is a less intensive level of service supply, or medication or more cost-effective alternative which can be safely and effectively provided, or if the service, supply, or medication can be safely and effectively provided to you in a less intensive setting 81

Acupuncture, aromatherapy, alternative medicine biofeedback, hypnotherapy, and massage therapy (including myotherapy) 81

All charges over the semi-private room rate, except when a private room is Medically Necessary 81

Any clinical research trial other than a Qualified Clinical Trial for the treatment of cancer (see page 105 for the definition of a Qualified Clinical Trial). 81

Any home adaptations, including, but not limited to, home improvements and home adaptation equipment 81

Any form of surrogacy 81

Any services not specified in this Benefit Handbook and your Schedule of Benefits 81

Any service or supply furnished along with a non-covered service 81

Services related to autism spectrum disorders provided under an individualized education program (IEP), including any services provided under an IEP that are delivered by school personnel or any services provided under an IEP purchased from a contractor or vendor. 81

Blood and blood products 81

Care by a chiropractor that falls outside the scope of standard chiropractic practice, including but not limited to, surgery, prescription or dispensing of drugs or medications, internal examinations, obstetrical practice, treatment of infectious disease, treatment with crystals, or diagnostic testing for chiropractic care other than an initial x-ray 81

Charges for any products or services, including, but not limited to, professional fees, medical equipment, drugs, and Hospital or other facility charges, that are related to any care that is not a Covered Service under this Benefit Handbook 81

Charges for missed appointments 81

Charges for services received after the date on which your membership ends 81

Commercial diet plans, weight loss programs, and any services in connection with such plans or programs 81

Cosmetic procedures, including those for mental health reasons, except as described in your Benefit Handbook for post-mastectomy or reconstructive surgery 81

Costs for services covered by workers' compensation, third party liability, other insurance coverage or an employer under state or federal law 81

Dental services, except the specific dental services listed in this Benefit Handbook. This exclusion includes, but is not limited to: (a) dental services for temporomandibular joint dysfunction (TMD); (b) restorative, periodontal, orthodontic, endodontic, prosthodontic services: dental fillings; crowns; gum care, including gum surgery; braces; root canals; bridges; and bonding are not covered except when Medically Necessary for the treatment of cleft lip or cleft palate; and (c) dentures, 81

Devices or special equipment needed for sports or occupational purposes 81

Devices and procedures intended to reduce snoring including, but not limited to, laser-assisted uvulopalatoplasty, somnoplasty, and snore guards 81

Any products or services, including, but not limited to drugs, devices, treatments, procedures, and diagnostic tests, which are Experimental, Unproven, or Investigational 81

Educational services and testing, including psychological testing and neuropsychological assessment related to educational services and testing. No benefits are provided: (1) for educational services intended to enhance educational achievement; (2) to resolve problems of school performance; or (3) to treat learning disabilities 81

Electrolysis, routine foot care services, biofeedback, hypnotherapy, psychoanalysis, pain management programs, massage therapy (including myotherapy), sports medicine clinics, services by a personal trainer, cognitive rehabilitation programs, and cognitive retraining programs 81

Eyeglasses, contact lenses and fittings, except as listed in your Schedule of Benefits as well as this Benefit Handbook 81

Gender reassignment surgery, including related drugs or procedures 81

Any services or supplies furnished by, or covered as a benefit under, a program of any government or its subdivisions or agencies except for the following: (a) a benefit plan established for its civilian employees, (b) Medicare (Title XVIII of the Social Security Act), (c) Medicaid (any state medical assistance program under Title XIX of the Social Security Act), or (d) a program of hospice care. 81

Group diabetes training or educational programs or camps 82

Hair removal or restoration, including, but not limited to, electrolysis, laser treatment, transplantation or drug therapy 82

Health resorts, recreational programs, camps, wilderness programs, outdoor skills programs, relaxation or lifestyle programs, including any services provided in conjunction with, or as part of such types of programs 82

Hearing aid batteries and any device used by individuals with hearing impairment to communicate over the telephone or internet, such as TTY or TDD. 82

Hospital charges with dates of service after your hospital discharge 82

Infertility treatment for Members who are not medically infertile 82

Mental health services that are (1) provided to Members who are confined or committed to a jail, house of correction, prison, or custodial facility of the Department of Youth Services or (2) provided by the Department of Mental Health 82

Non-durable medical equipment, unless used as part of the treatment at a medical facility or as part of approved home health care services 82

Personal comfort or convenience items (including telephone and television charges); non-durable medical supplies, unless used in the course of diagnosis or treatment in a medical facility or in the course of authorized home health care; exercise equipment; and repair or replacement of durable medical equipment or prosthetic devices as a result of loss, negligence, willful damage, or theft 82

Physical examinations or services for school, sports, camp, insurance, licensing, premarital or employment purposes which are not otherwise Medically Necessary 82

Planned home births 82

Preventive dental care 82

Refractive eye surgery, including laser surgery and orthokeratology, for correction of myopia, hyperopia and astigmatism 82

Rest or Custodial Care 82

Reversal of voluntary sterilization (including any services for infertility related to voluntary sterilization or its reversal) and the costs of achieving pregnancy through surrogacy 82

Sclerotherapy for the treatment of spider veins 82

Sensory integrative praxis tests 82

Services for disabilities related to military service 82

Services for a newborn who has not been enrolled as a Member, other than nursery charges for routine services provided to a healthy newborn for up to 30 days after the newborn’s birth 82

Services for any condition with only a “V Code” designation in the Diagnostic and Statistical Manual of Mental Disorders, which means that the condition is not attributable to a mental disorder 82

Services for cosmetic purposes, except as described in this Benefit Handbook for post-mastectomy services or reconstructive surgery 82

Services for non-Members and services after membership termination 82

Services for which no charge would be made in the absence of insurance 82

Services for which you are legally entitled to treatment at government expense. This includes services for disabilities related to military service 82

Services or supplies provided to you by: (1) anyone related to you by blood, marriage or adoption or (2) anyone who ordinarily lives with you 82

Services that are not Medically Necessary 82

Taxes or assessments on services or supplies 82

Any type of thermal therapy device 82

Therapeutic molded shoes, and foot orthotics, except for the treatment of severe diabetic foot disease 82

Transportation other than by ambulance 82

Vocational rehabilitation or vocational evaluations on job adaptability, job placement, or therapy to restore function for a specific occupation 82

Unless otherwise specified in the Schedule of Benefits or Benefit Handbook, the Plan does not cover food or nutritional supplements, including FDA-approved medical foods obtained by prescription 82



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