Professional services of physicians

• In physician’s office
• Second surgical opinion

Note: If the member chooses a non-Plan Physician for the second surgical opinion, the member will be responsible for 40% of the amount of reasonable and customary charges.

$25 per visit to your primary care physician

$45 per visit to a participating specialist

Professional services of physicians

• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Office medical consultation
• Advance care planning
• At home

Nothing

Note: AvMed's Telehealth Services provide anytime remote access to board-certified doctors from your home, your office, or on the go.  Just 15 minutes after a simple sign-up, members can speak with a doctor about non-emergency medical issues by phone or by secure video using a computer, tablet, or smartphone.  

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology

$25 per visit to your primary care physician

$45 per visit to a participating specialist

• X-rays
• Ultrasound
• Electrocardiogram and EEG
• CAT Scans/PET Scans/Magnetic Resonance Imagings (MRIs)

Note: Prior authorization is required.

20% of the contracted rate (calendar year deductible applies)

Routine physical annually:

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screening such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings, go to the U.S Preventive Service Task Force (USPTF) website at https://www.uspreventiveservicestaskforce.org.
• Individual counseling on prevention and reducing health risks
• Well woman care such as Pap smears, gonorrhea, prophylactic medications to protect newborns, annual counseling for sexually transmitting infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

Nothing

• Mammograms (Routine and non-routine)

• Adult Immunizations endorsed by the Centers for Disease Control and Prevention(CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. 

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive recommended listing of services will be subject to applicable member copayments, coinsurance, and deductible.

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Future Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTap, Poli, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

  Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive recommended listing of services will be subject to the applicable member cost-sharing (copayments, coinsurance, and deductible).

Nothing

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women
• Postnatal care

Nothing

• Delivery

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see page 18 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

A range of voluntary family planning services, limited to:

• Voluntary sterilization (e.g., tubal ligation, vasectomy) See surgical procedures Section 5(b).
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Interauterine devices (IUDs)
• Diaghragms
• Genetic testing

Note: All genetic testing requests will be reviewed for medical necessity.

Note:  We cover oral contraceptives under the prescription drug benefit.

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)

• Medically necessary hormone testing

• Semen analysis

• Sperm function testing

• Chromosomal analysis

• Medical imaging

• Surgical correction of genitourinary tract abnormalities

Note: Infertility is defined as the inability of an individual to achieve conception after one year of unprotected intercourse; or the inability of an individual to achieve conception after six trials of artificial insemination over a one-year period.  Infertility services require prior authorization.

$25 per visit to your primary care physician

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  - In vitro fertilization (IVF)
  - Embryo transfer, gamete intra-fallopian transfer(GIFT) and zygote intra-fallopian transfer(ZIFT)

• Artificial insemination (AI): 
  - Intracervical insemination (ICI) 
  - Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Surgery for the enhancement of fertility
• Cost of donor sperm
• Cost of donor egg
• Fertility drugs

• Testing and treatment

$50 per course of testing

• Allergy injections

$25 per office visit

Not covered:  

• Provocative food testing and sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 44.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 18 sessions
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 19.  Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633. 

$25 per visit to your primary care physician

Short-term therapy for acute condition for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvements for the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

• orders the care
• identifies the specific professional skills the patient requires and the medically necessity for skilled services; and
• indicates the length of time the services are needed.

$45 per visit to a participating specialist

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

Short-term speech therapy, when medically necessary, for acute conditions for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvement.

$25 per visit to your primary care physician

Coverage for Habilitative Services is covered the same as physical, occupational and speech therapy and includes services for Applied Behavior Analysis.

$25 per visit to primary care physician

$45 per visit for physical, occupational and speech therapies

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children.

Nothing

• External hearing aids (limited to $3,000 per year) and testing to fit them 
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

Not covered:

• Hearing services that are not shown as covered

• Annual eye refractions to determine the need for vision correction for children through age 17
• Diagnosis and treatment of diseases of the eye

Note: See Preventive care, children for eye exams for children. 

$25 per visit to your primary care physician

$45 per visit to a participating specialist

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as cataracts).

$45 per pair 

Not covered:

• All other vision testing (eye examinations and refractions)
• Eyeglasses or contact lenses (including replacement of lenses provided during the same calendar year)
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

$25 per visit to your primary care physician

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
• Podiatric shoe inserts or foot orthotics

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• External hearing aids and testing to fit them (External hearing aids limited to $3,000 per year)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) for Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Non orthopedic brace
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Penile implants 
• Prosthetic replacements provided less than 3 years after the last one we covered

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Standard wheelchairs
• Crutches
• Insulin pumps
• Ostomy and catheter supplies

Note:   Coverage for orthotic appliances is limited to leg, arm, back, and neck custom-made braces when related to a surgical procedure or when used in an attempt to avoid surgery and are necessary to carry out normal activities of daily living, excluding sports activities.  Coverage is limited to the first such item; repair and replacement is not covered.

Note:   Call us at 800-882-8633 as soon as your Plan physician  prescribes this equipment.  We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Not covered:

• Medical supplies such as corsets which do not require a prescription
• Audible prescription reading devices
• Speech generating devices
• Motorized wheelchairs
• Non-standard wheelchairs
• All other orthotic appliances

All charges

• Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

20% of the contracted rate (calendar year deductible applies)

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$25 per visit to your primary care physician

No benefit

Coverage is provided for :

• Tobacco Cessation programs, including individual/group/telephone counseling, and for over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for counseling for up to two quit attempts per year.
Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self-management

$25 per visit to your primary care physician

• Childhood obesity education

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay hospital benefits for a pacemaker and surgery benefits for insertion of the pacemaker.

Note: Morbid Obesity is a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over. 1. Weight loss surgery may be an option for a select group of patients with clinically severe obesity or morbid obesity. When non-evasive methods of weight reduction have been exhausted, surgery will be considered for individuals with a Body Mass Index (BMI) of greater than or equal to 40 or a BMI of 35 or greater, with coexisting conditions. Individuals may qualify for surgery if they have been morbidly obese for a period of five (5) years or more. Morbid obesity is defined as having a BMI in excess of 40 or a BMI in excess of 35 with any of the following severe co-morbidities: coronary heart disease, diabetes mellitus, clinically significant obstructive sleep apnea, and medically refractory hypertension; 2. Member has completed growth (18 years of age or documentation of bone growth completion); 3. Recent psychiatric/psychological evaluation to rule out eating disorder(s) or psychological disturbance, such as Binge Eating Disorder, active drug abuse, active suicidal ideations/thoughts, borderline personality disorder, schizophrenia, terminal illness or uncontrolled depression, which may impede post-operative recovery and dietary restrictions; 4. Documentation (e.g., type, duration, amount of weight loss) of all prior weight control/loss programs including: food supplements, appetite suppressants, dietary regimens/treatments, and exercise programs; 5. Documentation of non-operative, physician supervised integrated weight reduction program consisting of dietary therapy, appropriate exercise, behavior modification and psychological support: Four (4) physician visits are required over a six (6) month period to document supervision; the program must maintain at least a six (6) month duration, within three (3) years of request for surgical intervention.

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

Voluntary sterilization (e.g., tubal ligation, Vasectomy)

Nothing

Treatment of burns

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:

-  the condition produced a major effect of the member’s appearance and

-  the condition can reasonably be expected to be corrected by such surgery

• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.  Examples of congenital anomalies  are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:

-  surgery to produce a symmetrical appearance of breasts;

-  treatment of any physical complications, such as lymphedemas;

-  breast prostheses and surgical bras and replacements (see Prosthetic devices)

• Gender reassignment surgery including mastectomy, gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female), and genital reconstruction (in female-to-male: vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular and erectile prosthesis; in male-to-female: penectomy, vaginoplasty, labiaplasty, and clitoroplasty).

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital  up to 48 hours after the procedure.   

Note:  Gender reassignment surgery may be covered when ALL of the following criteria are met:

1. At least one (1) Referral Letter from a qualified Psychologist or Psychiatrist indicating:

a. Results of the Member’s psychosocial assessment and diagnoses; and

b. Documentation and results of the type of evaluation and therapy or counseling to date; and

c. Documentation that the World Professional Association for Transgender Health (WPATH) criteria for surgery have been met and the specific clinical rationale for supporting the Member’s request for surgery; and

2. Documentation of persistent, well-documented Gender Dysphoria (DSM 5 criteria); and

3. Documentation of Member’s capacity to make a fully informed decision and to consent for treatment; and

4. Member is 18 years of age or older; and

5. Documentation of at least 12 months of continuous hormone therapy as appropriate to the Member's gender goals (Note: that a trial of hormone therapy is not a pre-requisite to qualify for a mastectomy.); and

6. Important Note - For those Members requesting genital reconstruction: Two (2) Psychiatric Letters of Referral are needed along with documentation of at least 12 months of living in a gender role that is congruent with their gender identity (real life experience).

Important Note: Coverage is limited to in-network AvMed participating providers only. Out of network benefits or exceptions do not apply to coverage of gender reassignment surgery.

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

Not covered:

• Feminizing procedures including Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.
• Masculinizing procedures including chin implants, nose implants, and lip reduction.  In addition, the following procedures are not covered:  Abdominoplasty, brow lift, calf implants, cheek/malar implants, chin/nose implants, collagen injections, liposuction, mastopexy, and pectoral implants.
• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
• Procurement, cryopreservation or storage of embryo, sperm, oocytes for the preservation of fertility and the cryopreservation, storage, and thawing of reproductive tissue (i.e., ovaries, testicular tissue).

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.
• TMJ (non-dental)

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Impacted wisdom teeth

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 19. The medical necessity limitation is considered satisfied for other tissue transplants if the patient meets the staging description and can safely tolerate the procedure.  
Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas 
• Kidney
• Kidney/pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas 

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced neuroblastoma 
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Aplastic anemia
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Infantile malignant osteopetrosis
• Kostmann's syndrome
• Leukocyte adhesion deficiencies
• Marrow Failure and Related Disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
• Mucolipidosis(e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccaridosis(e.g., Hunter's syndrome, Hurler's syndrome, Sanfilippo's syndrome, Maroteaux-Lamy syndrome variants)
• Myelodysplasia/Myelodysplastic syndromes
• Myeloproliferative disorders
• Paroxysmal Nocturnal Hemoglobinuria 
• Phagocytic/Hemophagocytic deficiency diseases (e.g, Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia/pediatric
• X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial Ovarian Cancer
  • Ewing's sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom's macroglobulinemia
• Autogolous tandem transplants for recurrent germ cell tumors (including testicular cancer)

Note: Treatment must be approved by the Plan’s medical director in accordance with the Plan’s protocols. AvMed will request the medical evidence we need to make our coverage determination.

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/ small lymphocytic lymphoma (CLL/SLL) 
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Multiple Myeloma
  • Multiple Sclerosis
  • Myleoproliferative Disorders
  • Myelodysplasia/Myelodysplastic syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Paroxysmal Nocturnal Hemoglobinuria
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell disease 

• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/ small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphom
  • Neuroblastoma
  • Small cell lung cancer                                                                   

• Autologous transplants for the following autoimmune diseases:
  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc(severe, progessive)
  • Systemic lupus erythematosus
  • Systemic sclerosis

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogenic transplants for: 
  • Beta Thalassemia Major 
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Autologous transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Aggressive non-Hodgkin’s lymphomas(Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

$25 per visit billed by your primary care physician

$45 per visit billed by a participating specialist

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

Nothing

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

$300 a day for the first three days per admission

(calendar year deductible applies) 

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood or blood plasma, only if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care, except when medically necessary

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia services

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.  If you have outpatient surgery and it turns into Observation care that exceeds 24 hours, only outpatient surgery copay will apply.

$300 copay per visit

• Bed, board and general nursing care;
• Drugs biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

We provide supportive and palliative care for a terminally ill member in the home or hospice facility.  Services include:

• Inpatient and outpatient care;
• Family counseling

Note: These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Local professional ambulance  service, including air ambulance, when medically appropriate and ordered or authorized by a Plan doctor.

Nothing

• Emergency care at a participating doctor’s office

$25 per visit to your primary care physician

$45 per visit to your participating specialist

• Emergency care at a participating urgent care center

$40 per visit

• Emergency care at a non-participating urgent care center

$60 per visit

• Emergency care at a hospital emergency room

Note: We waive the ER copay if you are admitted to the hospital.  If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER copay will apply.

• Emergency care at a doctor’s office
• Emergency care at an urgent care center

$60 per visit

• Emergency care at a hospital emergency room

Note: We waive the ER copay if you are admitted to the hospital.  If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER copay will apply.

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

• Professional ambulance service when medically appropriate.
• Air ambulance, when medically necessary and preauthorized by Medical Director or Chief Medical Officer.

Note: See 5(c) for non-emergency service.

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management  (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy
• Applied Behavioral Analysis services

$25 per visit to your primary care physician

$45 per visit to a participating specialist

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

$25 per visit to your primary care physician

$45 per visit to a participating specialist

20% of the contracted rate (calendar year deductible applies)

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

$300 a day for the first three days per admission

(Calendar year deductible applies)

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

$300 per visit

(Calendar year deductible applies)

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  - Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Growth hormone medication

Note: Prior authorization required for sexual dysfunction drugs. Coverage is limited; contact AvMed for dose limits. You pay the corresponding drug copayment up to the dosage limit and all charges above that.

Note: Growth hormone therapy is covered under the medical benefit.

Note: We only cover growth hormone medication when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 19.  Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633. 

Note: Your Specialty medication prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the manufacturers packaging guidelines but not more than a 30 day supply per coinsurance or actual cost, whichever is less.

Note: Opioid medications are covered under a quantity limit of 90 Morphine Milligram Equivalent (MME) per 30-day supply and a step therapy requirement for long acting opioids which require the use of a short-acting opioid first.  As part of the prior authorization process, the Plan will provide advance warning to members approaching the MME quantity limit.  There is also a 3-day limit on the initial fill for patients with acute conditions new to therapy with the option of up to a 7-day supply if deemed medically necessary by a physician.

Note: We have an out-of-pocket maximum of $2,500 per member per calendar year on the Specialty medication benefit.

Note: Mail service is a benefit option for maintenance medications needed for chronic or long-term health conditions. It’s best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Pay the following copayment (as well as the cost difference if you or your physician choose a name Brand drug when there is an FDA-approved Generic).

Retail Drugs (30-day supply)

$10 Generic Drugs (Tier 1)

$40 Preferred Brand Name Drugs (Tier 2)

$60 Non-Preferred Brand Name and Generic Drugs (Tier 3)

30% coinsurance Specialty Medication (Tier 4)

Mail Order Drugs (up to 90-day supply)

$30 Generic Drugs (Tier 1)

$120 Preferred Brand Name Drugs (Tier 2)

$180 Non-Preferred Brand Name and Generic Drugs (Tier 3)

Specialty drugs are not covered under Mail Order.

Note: If there is no generic equivalent available, you will still have to pay the brand name copay. 

• Medical foods for children with inborn errors of metabolism up to age 24, or age 14 for Organic Acid Disorders (OAD) and Amino Acid Disorders (AAD).

Note: Medical foods are foods that are specifically formulated and intended for the dietary management of a disease that has distinctive nutritional needs that cannot be met by normal diet alone.  Prescription is required. 

Note: Limited to $2,500 per calendar year.

20% of the contracted rate (calendar year deductible applies)

• Women's contraceptive drugs and devices

Note: Over-the-counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider.

Here are some things to keep in mind about our prescription drug program:

• When you have a prescription filled, a Generic equivalent to a name Brand drug will be dispensed. If you or your physician choose a name Brand drug when there is a FDA-approved Generic equivalent to that name Brand drug, you have to pay the difference in cost between the name Brand drug and the Generic drug plus the applicable Brand copayment. For name Brand drugs that do not have an FDA-approved Generic equivalent you will pay the applicable Brand copayment.

Not covered:

• Drugs and supplies for cosmetic purposes.
• Drugs to enhance athletic performance.
• Fertility drugs.
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Nonprescription medications or medications for which there is a nonprescription alternative.
• Medical supplies, including therapeutic devices, dressings, antiseptics, appliances, and support garments.
• Compounded prescriptions, except pediatric preparations.
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss.
• Medications for non-business related travel, including transdermal scopolamine, i.e. motion sickness patches.
• Replacement prescription products resulting from a lost, stolen, expired, broken, or destroyed prescription orders for refill.
• Medications that require preauthorization and for which preauthorization is denied or not obtained by a physician.
• Medications for dental purposes, including fluoride medications, antibiotics and pain medications for dental care.

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit and we require a written prescription by an approved provider. (See page 56.)

All charges

The following drugs and supplements are covered, even if over-the-counter, if prescribed by a health care professional and filled at a network pharmacy. 

• Aspirin (81 mg) for men 45-79 and women age 55-79 and women of childbearing age. 
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for child age 0-1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin use for the Primary Prevention of Cardiovascular Disease for adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater
• Naloxone-based rescue agents for the prevention of opioid overdose related deaths

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy.  To receive this benefit, a prescription from a doctor must be presented to pharmacy.  For current recommendations, go to www.uspreventiveservicetaskforce.org/BrowseRec/Index/browse-recommendations.

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
• Nonprescription medications

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit (See page 56).

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

We have no other dental benefits.

All charges

Routine physical annually:

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

• Screening such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings, go to the U.S Preventive Service Task Force (USPTF) website at https://www.uspreventiveservicestaskforce.org.
• Individual counseling on prevention and reducing health risks
• Well woman care such as Pap smears, gonorrhea, prophylactic medications to protect newborns, annual counseling for sexually transmitting infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

Nothing

Routine Prostate Specific Antigen (PSA) test - one annually for men age 40 and older

Nothing

Mammograms (Routine and non-routine)

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

Well-child visits examinations, and immunizations as described in the Bright Future Guidelines provided by the American Academy of Pediatrics

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and not included in the preventive listing of services will be subject to the recommmended member copayments, coinsurance, and deductible.

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force is available (USPSTF) is available online at: www.uspreventiveservicestaskforce.org

HHS: www.healthcare.gov/preventive-care-benefits/

ACIP recommendations on immunizations, please refer to the National Immunization Program Web site at: www.cdc.gov/vaccines/schedules/index.html

CDC: www.cdc.gov/vaccines/schedules/index.html  

For additional information:

www.healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to brightfutures.aap.org/Pages/default.aspx

Nothing

The deductible applies to almost all benefits in this Section. In the You pay column, we say “(deductible does not apply)” when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,500 per person, $3,000 per Self Plus One enrollment or $3,000 per Self and Family enrollment.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay the indicated coinsurance or copayments for covered services. You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.

Out-of-network: After you meet the deductible, you pay the indicated coinsurance based on our Plan allowance and any difference between our allowance and the billed amount.

Professional services of physicians:

• In physician’s office
• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Office medical consultations
• Second surgical opinion
• At home
• Advance care planning

20% of the contracted rate 

Note: AvMed's Telehealth Services provide anytime remote access to board-certified doctors from your home, your office, or on the go. Just 15 minutes after a simple sign-up, Members can speak with a doctor about non-emergency medical issues by phone or by secure video using a computer, tablet, or smartphone. 

Nothing (deductible does not apply)

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• CAT Scans/MRIs
• Ultrasound
• Electrocardiogram and EEG

20% of the contracted rate 

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women
• Delivery
• Postnatal care

20% of the contracted rate 

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see page 18 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Nothing (deductible does not apply)

Contraceptive counseling on an annual basis

Nothing (deductible does not apply)

A range of voluntary family planning services, limited to:

• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Genetic testing (Note: All genetic testing requests will be reviewed for medical necessity.)

Note: We cover oral contraceptives under the prescription drug benefit.

Nothing (deductible does not apply)

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling

All charges

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  - Intravaginal insemination (IVI)
• Medically necessary hormone testing
• Semen analysis
• Sperm function testing
• Chromosomal analysis
• Medical imaging
• Surgical correction of genitourinary tract abnormalities

Note: Infertility is defined as the inability of an individual to achieve conception after one year of unprotected intercourse; or the inability of an individual to achieve conception after six trials of artificial insemination over a one-year period. Infertility services require prior authorization.

20% of the contracted rate 

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  - In vitro fertilization (IVF)
  - Embryo transfer, gamete intra-fallopian transfer(GIFT) 
  - Zygote intra-fallopian transfer(ZIFT)
• Artificial insemination (AI):
  - Intracervical insemination (ICI)
  - Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Surgery for the enhancement of fertility
• Cost of donor sperm
• Cost of donor egg
• Fertility drugs

All charges

• Testing and treatment
• Allergy injections
• Allergy serum

20% of the contracted rate 

Not covered:

• Provocative food testing and sublingual allergy desensitization

All charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 93.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 18 sessions.
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19.  Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633.

20% of the contracted rate 

Short-term therapy for acute condition for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvements for the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

• Orders the care
• Identifies the specific professional skills the patient requires and the medically necessity for skilled services; and
• Indicates the length of time the services are needed.

20% of the contracted rate 

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

Short-term speech therapy, when medically necessary, for acute condition for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvement.

20% of the contracted rate 

Coverage for Habilitative Services is covered the same as physical, occupational and speech therapy and includes services for Applied Behavior Analysis.

20% of the contracted rate 

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see HDHP Section 5. Preventive Care, children.

Nothing (deductible does not apply)

• External hearing aids (limited to $3,000 per year)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see HDHP Section 5. Preventive Care, children. 

20% of the contracted rate 

Not covered:

• Hearing services that are not shown as covered

All charges

• Annual eye refractions to determine the need for vision correction for children through age 17
• Diagnosis and treatment of diseases of the eye

Note: See Preventive care, children for eye exams for children.

20% of the contracted rate 

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as cataracts).

20% of the contracted rate 

Not covered:

• All other vision testing (eye examinations and refractions)
• Eyeglasses or contact lenses (including replacement of lenses provided during the same calendar year)
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
• Podiatric shoe inserts or foot orthotics

20% of the contracted rate 

• Artificial limbs and eyes
• Prosthetic sleeve and sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• External hearing aids and testing to fit them (External hearing aids limited to $3,000 per year)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and anesthesia services. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

20% of the contracted rate 

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Non orthopedic base
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Penile implants
• Prosthetic replacements provided less than {X} years after the last one we covered

All charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Standard Wheelchairs
• Crutches
• Walkers
• Insulin pumps
• Ostomy and catheter supplies

Note: Call us at 888-882-8633 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of the contracted rate 

Not covered:

• Medical supplies such as corsets which do not require a prescription
• Audible prescription reading devices
• Speech generating devices
• Motorized wheelchairs
• Non-standard wheelchairs
• All other orthotic appliances

All charges

• Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

20% of the contracted rate 

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

All charges

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

20% of the contracted rate 

No benefit

All charges

Coverage is provided for:

Tobacco Cessation programs, including individual/group/telephone counseling, and for over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

(deductible does not apply)

Diabetes self management

20% of the contracted rate 

Childhood obesity education

Nothing (deductible does not apply)

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery)
• Insertion of internal prosthetic devices.  See HDHP Option Section 5(a) Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay hospital benefits for a pacemaker and surgery benefits for insertion of the pacemaker.

Note: Morbid Obesity is a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over. 1. Weight loss surgery may be an option for a select group of patients with clinically severe obesity or morbid obesity. When non-evasive methods of weight reduction have been exhausted, surgery will be considered for individuals with a Body Mass Index (BMI) of greater than or equal to 40 or a BMI of 35 or greater, with coexisting conditions. Individuals may qualify for surgery if they have been morbidly obese for a period of five (5) years or more. Morbid obesity is defined as having a BMI in excess of 40 or a BMI in excess of 35 with any of the following severe co-morbidities: coronary heart disease, diabetes mellitus, clinically significant obstructive sleep apnea, and medically refractory hypertension; 2. Member has completed growth (18 years of age or documentation of bone growth completion); 3. Recent psychiatric/psychological evaluation to rule out eating disorder(s) or psychological disturbance, such as Binge Eating Disorder, active drug abuse, active suicidal ideations/thoughts, borderline personality disorder, schizophrenia, terminal illness or uncontrolled depression, which may impede post-operative recovery and dietary restrictions; 4. Documentation (e.g., type, duration, amount of weight loss) of all prior weight control/loss programs including: food supplements, appetite suppressants, dietary regimens/treatments, and exercise programs; 5. Documentation of non-operative, physician supervised integrated weight reduction program consisting of dietary therapy, appropriate exercise, behavior modification and psychological support: Four (4) physician visits are required over a six (6) month period to document supervision; the program must maintain at least a six (6) month duration, within three (3) years of request for surgical intervention.

20% of the contracted rate 

• Voluntary sterilization (e.g. tubal ligation, Vasectomy)

Nothing (deductible does not apply)

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedemas
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)
• Gender reassignment surgery including mastectomy, gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female), and genital reconstruction (in female-to-male: vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular and erectile prosthesis; in male-to-female: penectomy, vaginoplasty, labiaplasty, and clitoroplasty).

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Note: Gender reassignment surgery may be covered when ALL of the following criteria are met:

1. At least one (1) Referral Letter from a qualified Psychologist or Psychiatrist indicating:                                                                                                  
    a. Results of the Member’s psychosocial assessment and diagnoses; and                                                                                                                     
    b. Documentation and results of the type of evaluation and therapy or counseling to date; and                                                                                      
    c. Documentation that the World Professional Association for Transgender Health (WPATH) criteria for surgery have been met and the specific clinical       rationale for supporting the Member’s request for surgery; and
2. Documentation of persistent, well-documented Gender Dysphoria (DSM 5 criteria); and
3. Documentation of Member’s capacity to make a fully informed decision and to consent for treatment; and
4. Member is 18 years of age or older; and
5. Documentation of at least 12 months of continuous hormone therapy as appropriate to the Member's gender goals (Note: that a trial of hormone therapy is not a pre-requisite to qualify for a mastectomy.); and
6. Important Note - For those Members requesting genital reconstruction: Two (2) Psychiatric Letters of Referral are needed along with documentation of at least 12 months of living in a gender role that is congruent with their gender identity (real life experience).

Important Note: Coverage is limited to in-network AvMed participating providers only. Out of network benefits or exceptions do not apply to coverage of gender reassignment surgery.

20% of the contracted rate 

Not covered:

• Feminizing procedures including Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.
• Masculinizing procedures including chin implants, nose implants, and lip reduction. In addition, the following procedures are not covered: Abdominoplasty, brow lift, calf implants, cheek/malar implants, chin/nose implants, collagen injections, liposuction, mastopexy, and pectoral implants.
• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury.
• Procurement, cryopreservation or storage of embryo, sperm, oocytes for the preservation of fertility and the cryopreservation, storage, and thawing of reproductive tissue (i.e., ovaries, testicular tissue).

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures
• TMJ (non-dental)

20% of the contracted rate 

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Impacted wisdom teeth

All charges

These solid organ transplants are covered. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney/pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

Note: Subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 16. The medical necessity limitation is considered satisfied for other tissue transplants if the patient meets the staging description and can safely tolerate the procedure.

20% of the contracted rate 

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for:
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

20% of the contracted rate 

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Aplastic anemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Myeloproliferative disorders
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial Ovarian Cancer
  • Ewing’s sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom's macroglobulinemia
• Autogolous tandem transplants for recurrent germ cell tumors (including testicular cancer)

Note:  Treatment must be approved by the Plan's medical director in accordance with the Plan's protocols.  AvMed will request the medical evidence we need to make our coverage determination.

20% of the contracted rate 

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/ small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Multiple Myeloma
  • Multiple Sclerosis
  • Myleoproliferative Disorders
  • Myelodysplasia/Myelodysplastic syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Paroxysmal Nocturnal Hemoglobinuria
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell disease

• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/ small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Neuroblastoma
  • Small cell lung cancer

• Autologous transplants for the following autoimmune diseases:
  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc(severe, progessive)
  • Systemic lupus erythematosus
  • Systemic sclerosis

20% of the contracted rate 

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

• Allogenic transplants for:
  
  • Beta Thalassemia Major
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Autologous transplants for:
• Advanced Childhood kidney cancers
• Advanced Ewing sarcoma
• Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms
• Breast Cancer
• Childhood rhabdomyosarcoma
• Epithelial Ovarian Cancer 
• Mantle Cell (Non-Hodgkin lymphoma)

Note:  Treatment must be approved by the Plan's medical director in accordance with the Plan's protocols.  AvMed will request the medical evidence we need to make our coverage determination.

20% of the contracted rate

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

All charges

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

20% of the contracted rate 

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

20% of the contracted rate 

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

20% of the contracted rate 

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.  If you have outpatient surgery and it turns into Observation care that exceeds 24 hours, only outpatient surgery cost share will apply.

20% of the contracted rate 

Not covered: Blood and blood derivatives not replaced by the member

All charges

Extended care benefit:

We provide a comprehensive range of benefits for up to 30 post-hospital days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are:

• Bed, board and general nursing care;
• Drugs biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

20% of the contracted rate 

Not covered: Custodial care

All charges

We provide supportive and palliative care for a terminally ill member in the home or hospice facility. Services include:

• Inpatient and outpatient care;
• Family counseling

Note: These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

20% of the contracted rate 

Not covered: Independent nursing, homemaker services

All charges

Local professional ambulance service including air ambulance, when medically appropriate and ordered or authorized by a Plan doctor. 

20% of the contracted rate 

• Emergency care at a doctor’s office
• Emergency care at a participating urgent care center
• Emergency care at a non-participating urgent care center
• Emergency care at a hospital emergency room

Note: We waive the ER copay if you are admitted to the hospital.  If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER cost share will apply.

20% of the contracted rate 

Not covered: Elective care or non-emergency care

All charges

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital. If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER cost share will apply.

20% of the contracted rate 

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

• Professional ambulance service when medically appropriate.
• Air ambulance, when medically necessary and preauthorized by Medical Director of Chief Medical Officer. 

Note: See 5(c) for non-emergency service.

20% of the contracted rate 

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy
• Applied Behavioral Analysis services

20% of the contracted rate

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

20% of the contracted rate 

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

20% of the contracted rate 

Outpatient services provided and billed by a hospital or other covered facility

• Services such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

20% of the contracted rate 

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  - Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction 
• Growth hormone medication

Note: Prior authorization required. Coverage is limited; contact AvMed for dose limits. You pay the corresponding drug copayment up to the dosage limit and all charges above that.

Note: Growth hormone therapy is covered under the medical benefit.

Note: We only cover growth hormone medication when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19. Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633.

Note: Your Specialty medication prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the manufacturers packaging guidelines but not more than a 30 day supply per coinsurance or actual cost, whichever is less.

Note: Opioid medications are covered under a quantity limit of 90 Morphine Milligram Equivalent (MME) per 30-day supply and a step therapy requirement for long acting opioids which require the use of a short-acting opioid first.  As part of the prior authorization process, the Plan will provide advance warning to members approaching the MME quantity limit.  There is also a 3-day limit on the initial fill for patients with acute conditions new to therapy with the option of up to a 7-day supply if deemed medically necessary by a physician.

Note: Mail service is a benefit option for maintenance medications needed for chronic or long-term health conditions. It’s best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Pay the following copayment (as well as the cost difference if you or your physician choose a name Brand drug when there is an FDA-approved Generic).

Retail Drugs (30-day supply)

$10 Generic Drugs (Tier 1)

$30 Preferred Brand Name Drugs (Tier 2)

$50 Non-Preferred Brand Name and Generic Drugs (Tier 3)

$75 Specialty Medication (Tier 4)

Mail Order Drugs (up to a 90-day supply)

$30 Generic Drugs (Tier 1)

$90 Preferred Brand Name Drugs (Tier 2)

$150 Non-Preferred Brand Name and Generic Drugs (Tier 3)

Specialty drugs are not covered under Mail Order

Note: If there is no generic equivalent available, you will still have to pay the name brand copay.

• Medical foods for children with inborn errors of metabolism up to age 24, or age 14 for Organic Acid Disorders (OAD) and Amino Acid Disorders (AAD).

Note: Medical foods are foods that are specifically formulated and intended for the dietary management of a disease that has distinctive nutritional needs that cannot be met by normal diet alone. Prescription is required.

Note: Limited to $2,500 per calendar year.

20% of the contracted rate 

• Women's contraceptive drugs and devices

Note: Over-the-counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider.

Here are some things to keep in mind about our prescription drug program:

• When you have a prescription filled, a Generic equivalent to a name Brand drug will be dispensed. If you or your physician choose a name Brand drug when there is a FDA-approved Generic equivalent to that name Brand drug, you have to pay the difference in cost between the name Brand drug and the Generic drug plus the applicable Brand copayment. For name Brand drugs that do not have an FDA-approved Generic equivalent you will pay the applicable Brand copayment.

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes.
• Drugs to enhance athletic performance.
• Fertility drugs.
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Nonprescription medications
• Medical supplies, including therapeutic devices, dressings, antiseptics, appliances, and support garments.
• Compounded prescriptions, except pediatric preparations.
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss.
• Medications for non-business related travel, including transdermal scopolamine, i.e. motion sickness patches.
• Replacement prescription products resulting from a lost, stolen, expired, broken, or destroyed prescription orders for refill.
• Medications that require preauthorization and for which preauthorization is denied or not obtained by a physician.
• Medications for dental purposes, including fluoride medications, antibiotics and pain medications for dental care.

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit and we require a written prescription by an approved provider. (See page 85.)

The following are covered:

Note:  Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

All charges

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit. (See page 85.)

All charges

The following drugs and supplements are covered, even if over-the-counter, if prescribed by a health care professional and filled at a network pharmacy.

• Aspirin (81 mg) for men 45-79 and women age 55-79 and women of childbearing age.
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for child age 0-1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin use for the Primary Prevention of Cardiovascular Disease for adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater.
• Naloxone-based rescue agents for the prevention of opioid overdose related deaths.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy.  To receive this benefit, a prescription from a doctor must be presented to pharmacy.  For current recommendations, go to www.uspreventiveservicetaskforce.org/BrowseRec/Index/browse-recommendations.

Nothing

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

20% of the contracted rate 

We have no other dental benefits

All charges

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)