Description of Benefits

Description of Benefits

 

The following section contains a description of your covered services as a member of the plan, including any limitations or exclusions related to each specific benefit. Please note: Our General exclusions and limitations section contains additional limitations that you should be aware of.

Covered services are health care services or supplies for which the plan will pay benefits. A service is covered according to the terms and conditions described in this Member Handbook only if it is medically necessary, provided by your PCP or another plan provider (except in emergency situations), and in some cases, authorized by the plan. Your Schedule of Benefits describes your costs for the benefits that you use.

Ambulance services
Ambulance services

Emergencies
In an emergency, where a prudent layperson could reasonably believe that a medical condition requires immediate care to prevent serious harm, the plan covers ambulance transportation from the place where a plan member is injured or stricken by illness to the nearest hospital where treatment can be given. Call your local emergency communications system (e.g., police or fire department, or 911) to request an ambulance. For more information about emergency situations, see Emergency care.

The type of ambulance used (air ambulance, land ambulance, etc.) must be appropriate to medical and geographic conditions. Emergency ambulance services do not require prior authorization.

Nonemergency situations
Ambulance service for medical treatments and procedures may be provided for certain nonemergency situations, when medically necessary. Any such services require prior authorization. This may include ambulance transportation to return to the closest available medical facility capable of providing those services, as determined by FHLAC. It may include ambulance transportation to the contiguous United States (not necessarily the FCHP service area) following an emergency inpatient admission which occurs outside of the country.

FHLAC will determine whether you need to be transported to the nearest point in the contiguous United States or all the way to the FCHP service area based upon your medical condition and upon the adequacy of the care available to you while you are away from the service area.

Transportation by any other means must be contraindicated by your medical condition in order to be considered.

Chair van or medivan transportation may be authorized in lieu of ambulance transportation. FHLAC reserves the right to determine the appropriate vehicle that meets criteria for transportation.

Covered Services

  1. Ambulance transportation for an emergency
  2. Ambulance transportation for nonemergency situations, when medically necessary

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Ambulance, chair van and/or medivan use for patient convenience, or transportation services only, including transportation to and from medical appointments
  2. Transfers between hospitals when your medical condition does not require that you be transported to another facility
  3. Air ambulance, when not appropriate to medical and geographical conditions
  4. Commercial airline transportation
  5. Taxi services
Autism services
Autism services

The plan covers benefits for the diagnosis and treatment of autism spectrum disorder. Benefits are only available to members who are residents of Massachusetts or whose principal place of employment is in Massachusetts. Diagnosis includes medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has one of the autism disorders. Treatment includes care prescribed, provided or ordered for an individual diagnosed with one of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary.

Covered Services

  1. Habilitative or rehabilitative care, professional counseling and guidance services and treatment programs, including, but not limited to, applied behavior analysis supervised by a board certified analyst. Services require plan authorization.
  2. Therapeutic care, services provided by licensed or certified speech therapists, occupational therapists, physical therapists or social workers. Therapeutic care requires plan authorization.
  3. Pharmacy care, medications prescribed by a licensed physician and health-related services deemed medically necessary to determine the need or effectiveness of the medications, to the same extent that pharmacy care is provided by the contract for other medical conditions.
  4. Psychiatric care, direct or consultative services provided by a psychiatrist licensed in the state in which the psychiatrist practices.
  5. Psychological care, direct or consultative services provided by a psychologist licensed in the state in which the psychologist practices.

Coverage for the diagnosis and treatment of autism spectrum disorders is not subject to any annual or lifetime dollar or unit of service limitation which is less than any annual or lifetime dollar or unit of service limitation imposed on coverage for the diagnosis and treatment of physical conditions nor subject to a limit on the number of visits an individual may make to an autism services provider.

The following terms shall have the following meaning:

Applied behavior analysis: The design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement and functional analysis of the relationship between environment and behavior.

Autism services provider: A person, entity or group that provides treatment of autism spectrum disorders.

Autism spectrum disorders: Any of the pervasive developmental disorders as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, including autistic disorder, Asperger’s disorder and pervasive developmental disorders not otherwise specified.

Board certified behavior analyst: A behavior analyst credentialed by the behavior analyst certification board as a board certified behavior analyst.

Durable medical equipment
Durable medical equipment and prosthetic/orthotic devices

The plan covers durable medical equipment (DME) and prosthetic/orthotic devices. Durable medical equipment and prosthetic/orthotic devices will be subject to coinsurance of 30% or match the coinsurance of all other benefits subject to coinsurance under the plan.

This plan covers prosthetic limbs which replace, in whole or in part, an arm or leg. These devices will be subject to 20% coinsurance or will match the coinsurance of all other benefits subject to coinsurance under the plan.

Most services require referral and prior authorization. (See Obtaining specialty care and services for more information.)

Durable medical equipment is defined as an item for external use that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in a patient’s home.

Durable medical equipment includes, but is not limited to, such items as:

  • Oxygen
  • Oxygen equipment
  • Respiratory equipment
  • Hospital beds
  • Wheelchairs
  • Crutches, canes and walkers
  • Breast pumps
  • Blood glucose monitors for home use, for the treatment of diabetes
  • Visual magnifying aids and voice synthesizers for blood glucose monitors, for use by diabetics who are legally blind
  • Therapeutic molded shoes and shoe inserts for the treatment of severe diabetic foot disease

Prosthetic devices are devices that replace all or part of an organ or body part (other than dental).

Some examples are:

  • Artificial limbs and eyes
  • Implanted corrective lenses needed after a cataract operation
  • Breast prosthesis
  • Parenteral/enteral nutrition therapy
  • Electric speech aids

Orthotic devices are “rigid or semi-rigid” devices that support part of the body and/or eliminate motion. Some examples are:

  • A form neck collar for cervical support
  • A molded body jacket for curvature of the spine (scoliosis)
  • An elbow or leg brace
  • Back, neck and leg braces with rigid supports, including orthopedic shoes that are part of braces
  • Splints

Covered Services

  1. The purchase or rental of durable medical equipment and prosthetic/orthotic devices (including the fitting, preparing, repairing and modifying of the appliance).
  2. Scalp hair prosthesis (wigs) for individuals who have suffered hair loss as a result of the treatment of any form of cancer or leukemia. Coverage is provided for up to $350 per member per calendar year when the prosthesis is determined to be medically necessary by a plan physician and the plan.
  3. Breast prosthesis that is medically necessary after a covered reconstructive surgery following a mastectomy.
  4. Oxygen and related equipment.
  5. Insulin pump and insulin pump supplies
  6. Hearing aids and supplies, when prescribed by a plan physician and obtained from a network provider

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Scalp hair prosthesis in excess of $350 per member per calendar year or for medical conditions other than those described above
  2. Items that are not covered include, but are not limited to:
    • Adjustable shoe-styling positioning devices, such as the Bebax™ Shoe.
    • Alcohol and alcohol wipes
    • Air conditioners, air cleaners or purifiers, dehumidifiers, humidifiers, HEPA filters and other filters, and portable nebulizers
    • Arch supports, foot orthotics or orthopedic shoes (except when part of a brace or for diabetic foot care ) or other supportive devices for the feet
    • Articles of special clothing, mattress and pillow covers, including hypoallergenic versions
    • Bed pans and bed rails
    • Bidets, bath and/or shower chairs
    • Comfort or convenience items such as telephone arms and over-bed tables
    • Dentures
    • Ear plugs (such as to prevent fluid from entering the ear canal during water activities or for sound/noise control)
    • Elevators, ramps, stair lifts, chair lifts, strollers and scooters
    • Exercise or sports equipment or similar devices
    • Eyeglasses and contact lenses (unless specifically covered in your Schedule of Benefits)
    • Heating pads, hot water bottles and paraffin bath units
    • Home blood pressure monitors and cuffs
    • Any home adaptations, including, but not limited to, home improvement and home adaptation equipment
    • Hot tubs, saunas, Jacuzzis, swimming pools or whirlpools
    • Incontinence products
    • Items that are considered experimental, investigational or not generally accepted in the medical community
    • Items not listed or listed as “not covered” on the durable medical equipment (DME) and medical and surgical supplies list
    • Items that do not meet the coverage criteria previously listed
    • Venous pressure stockings (such as TEDS or Jobst® stockings)
    • Raised toilet seats
    • Safety equipment, such as grab bars, car seats, seizure helmets, safety belts or harnesses, or vests
  3. Oxygen and related equipment, when obtained from a non-plan provider. This includes oxygen and related equipment that you are supplied with while you are out of the FCHP service area.
  4. Services that are not determined to be medically necessary. This applies even if the plan calendar year limits have not been reached.
Emergency and urgent care
Emergency and urgent care

Emergency care
The plan covers emergency care worldwide. When you experience an emergency medical condition, you should go to the nearest emergency room for care or call your local emergency communications system (e.g., police or fire department, or 911) to request ambulance transportation.

An emergency medical condition is a condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Serious jeopardy to the health of the individual (or unborn child)
  • Serious impairment to bodily functions or
  • Serious dysfunction of any bodily organ or part

Examples of covered emergencies are stroke, unconsciousness, heart attack symptoms or severe bleeding.

Emergency services do not require prior authorization. You should notify your PCP so that arrangements can be made to coordinate any needed follow-up care. You should be aware that follow-up care in an emergency room often will not meet a prudent layperson definition and that most emergency room follow-up care can be provided in a setting other than an emergency room.

Urgent care
Sometimes you may need care right away for minor emergencies such as cuts that require stitches, a sprained ankle or abdominal pain. These situations may not pose as much of a threat as the emergency situations discussed above, but they still require fast treatment to prevent serious deterioration of your health.

If you are within the FCHP service area, call your PCP’s office for information on how and where to seek treatment. If your doctor is not available, an on-call doctor will make arrangements for your care.

Telephones are answered 24 hours a day, seven days a week. Explain the medical situation to the doctor and state where you are calling from, so that the doctor can refer to you to the most appropriate facility.

If you are outside the FCHP service area, go to the nearest medical facility for care. If you need follow-up care, you should contact your PCP for assistance.

Covered Services

  1. Emergency room visits
  2. Emergency room visits when you are admitted to an observation room
  3. Emergency room visits when you are admitted as an inpatient
  4. Urgent care visits in a doctor’s office or at an urgent care facility
  5. Emergency prescription medication provided out of the FCHP Direct Care service area as part of an approved emergency treatment

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Non-emergency care provided in an emergency room
  2. Unauthorized in-area urgent care visits
  3. Out-of-area care or services that could have been anticipated before leaving the FCHP Direct Care service area
  4. Follow-up care, unless provided by your PCP, a Reliant Medical Group specialist (if you have a Reliant Medical Group PCP), or authorized by the plan. This includes follow-up care in an emergency room setting.
  5. Non-emergency prescription medication outside the FCHP Direct Care service area such as medication for a chronic condition or a maintenance supply. You may use the prescription medication mail-order program to fill medication refills. (See Prescription medication.)
  6. Care from a non-plan or out-of-area provider once you are medically able to return to the FCHP Direct Care service area
Home health care services
Home health care services

The plan covers medically necessary part-time or intermittent skilled nursing care and physical therapy provided in your home by a home health agency. Additional services such as occupational therapy, speech therapy, medical social work, nutritional consultation, the services of a home health aide, and the use of durable medical equipment and supplies are covered to the extent that they are determined to be medically necessary component of skilled nursing care and physical therapy. To be eligible for home health care, you must be confined to your home due to illness or injury and your doctor must establish a treatment plan that requires services including, but not limited to, nursing care and physical therapy.

Home health care services must be ordered by a plan physician. Home care provided by plan providers no longer requires prior authorization by FHLAC. DME provided in conjunction with home health care requires prior authorization. See Obtaining specialty care and services and Durable medical equipment and prosthetic/orthotic devices for more information. Members receiving skilled services must meet the homebound criteria.

Covered Services

  1. Part-time or intermittent skilled nursing care and physical therapy provided in your home by a home health agency
  2. Additional services and supplies that are determined to be a medically necessary component of skilled nursing care and physical therapy

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Personal comfort items
  2. Meals
  3. Housekeeping services and/or homemaking services
  4. Custodial care services and/or unskilled home health care, whether at home or in a facility setting
Hospice care
Hospice care

Hospice is a coordinated program of palliative and supportive care provided to plan members who are terminally ill and their families. Rather than trying to cure the illness, the goal of hospice is to make the plan member as comfortable as possible, ease pain and other troublesome symptoms and support the family through a difficult time.

Hospice care is provided by an interdisciplinary hospice team who understand the needs of patients who are terminally ill. The team includes doctors, nurses, social workers, spiritual counselors, home health aids, bereavement counselors and volunteers. Most hospice patients receive hospice care while continuing to live in the comfort of their own home. The hospice team will visit the home regularly and provide medical and nursing care, emotional support and counseling, instruction and practical help.

Hospice care requires a PCP referral and prior authorization. (See Obtaining specialty care and services for more information.)

Covered service
  1. Hospice care provided at home, in the community and in facilities.
Hospital inpatient services
Hospital inpatient services

The plan covers inpatient care for as many days as your condition requires. Your provider will work with FHLAC’s Care Coordination Department to develop a treatment plan for you.

If you are in a hospital or other medical facility when your coverage takes effect, you will be covered by the plan as of your effective date as long as you notify us as soon as medically possible that you are an inpatient. You must also allow a plan physician to assume further care. If medically appropriate, you may be transferred to a plan facility.

Hospital inpatient services require referral and prior authorization. (See Obtaining specialty care and services for more information on referral and prior authorization). Whenever you need to be admitted to a hospital for a medical procedure, your PCP and specialty care physician will work with FHLAC to obtain prior authorization at a plan facility to which your physician admits. Your physician and the plan also will monitor the care that you receive as an inpatient and coordinate your discharge from the hospital. While you are an inpatient, our utilization management program will review and evaluate the inpatient care that you receive to make sure that you receive appropriate care.

For more information about utilization management review, see the Utilization management section.

Covered Services

  1. Room and board in a semiprivate room or a private room when medically necessary
  2. The services and supplies that would ordinarily be furnished to you while you are an inpatient. These include, but are not limited to, diagnostic lab, pathology and X-ray services, anesthesia services, short-term rehabilitation, and operating and recovery room services
  3. Physician and surgeon services
  4. General nursing services
  5. Intensive and/or coronary care
  6. Dialysis services
  7. Medical, surgical or psychiatric services
  8. Nursing services provided by a certified registered nurse anesthetist

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Private room, unless medically necessary. If you desire a private room and it is not a medical necessity, you pay all additional room charges above the semiprivate room charge.
  2. Personal comfort items such as telephone, radio or television
  3. Charges that you incur for services not determined to be medically necessary by a plan physician and the plan, or when you choose to stay beyond the hospital discharge hour for your own convenience
  4. Rest or custodial care, or long-term care
  5. Autologous blood or blood donation or storage for use during surgery or other medical procedure
  6. Unskilled nursing home care
Infertility/assisted reproductive technology services
Infertility/assisted reproductive technology services

The plan covers the services shown below for diagnosis and treatment of infertility. Infertility means the condition of an individual who is unable to conceive or produce conception during a period of one year if the female is age 35 or younger or during a period of 6 months if the female is over age 35. If a person conceives but is unable to carry that pregnancy to live birth, the period of time she attempted to conceive prior to achieving that pregnancy shall be included in the calculation of the one year or six month period as applicable.

Approval for coverage of assisted reproductive technology (ART) is contingent upon review by a FHLAC medical director. FHLAC’s coverage guidelines for all ART services are available by contacting the Customer Service Department.

Infertility services require referral and prior authorization unless provided by a Reliant Medical Group specialist (if you have a Reliant Medical Group PCP). Certain fertility medications also require prior authorization; some may have a quantity limit for each prescription as well. See Obtaining specialty care and services for more information on referral and prior authorization.

Covered Services

  1. Office visits for the consultation, evaluation and diagnosis of fertility
  2. Diagnostic laboratory and X-ray services
  3. Artificial insemination, such as intrauterine insemination (IUI)
  4. Assisted reproductive technologies including, but not limited to:
    • In vitro fertilization (IVF-EP)
    • Gamete intrafallopian transfer (GIFT)
    • Zygote intrafallopian transfer (ZIFT)
    • Intracytoplasmic sperm injection (ICSI) for the treatment of male factor infertility or when preimplantation genetic diagnosis (PGD) testing is covered
    • PGD when the partners are known carriers for certain genetic disorders
  5. Sperm, egg, and/or inseminated egg procurement, processing and banking, to the extent that such costs are not covered by the donor ‘s insurer

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Services that are considered experimental or investigational.
  2. Services for a member who is not medically infertile.
  3. Services for a partner who is not a member.
  4. Services for women who are menopausal, except those women who are experiencing premature menopause.
  5. Donor sperm in the absence of documented male factor infertility, as evidenced by abnormal semen analysis or in men with genetic sperm defects
  6. Chromosome studies of a donor (sperm or egg).
  7. Preimplantation genetic diagnosis (PGD) for aneuploidy screening or other indications not listed under Covered services.
  8. Gender selection in the absence of a documented X-linked disorder.
  9. Treatments requested solely for the convenience, lifestyle, personal or religious preference of the member in the absence of medical necessity.
  10. Transportation costs to and from the medical facility
  11. Infertility services that are necessary as a result of a prior voluntary sterilization or unsuccessful sterilization reversal procedure.
  12. Supplies that may be purchased without a physician’s written order, such as ovulation test kits.
  13. Services related to achieving pregnancy through a surrogate or gestational carrier.
  14. Charges for the storage of donor sperm, eggs or embryo that remain in storage after the completion of an approved series of infertility cycles.
  15. Service fees, charges or compensation for the recruitment of egg donors (this exclusion does not include the charges related to the medical procedure of removing an egg for the purpose of donation when the recipient is a member of the plan).
  16. Sperm, egg and/or inseminated egg procurement, processing and banking of sperm or inseminated eggs, to the extent such costs are covered by the donor’s insurer.
  17. Infertility medication for donors
  18. Donation or sale of gametes or embryos
  19. Medications for ART cycles/attempts without prior authorization
  20. Clinical or laboratory research
Maternity services
Maternity services

The plan covers maternity and obstetrical care in accordance with the General Laws of Massachusetts. Routine obstetrical and maternity care does not require a referral or prior authorization, but you need
to see a plan provider who is an obstetrician, certified nurse midwife or family practice physician. See Obtaining specialty care and services for more information.

Covered Services

  1. Obstetrical services including prenatal, childbirth, postnatal and postpartum care
  2. Inpatient maternity care for a minimum of 48 hours of care following a vaginal delivery, or 96 hours of care following a Caesarean section delivery. The covered length of stay may be reduced if the mother and the attending physician agree upon an earlier discharge.
  3. If you or your newborn are discharged earlier, you are covered for home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests; provided, however that the first home visit shall be conducted by a registered nurse, physician or certified nurse midwife; and provided further, that any subsequent home visit determined to be clinically necessary shall be provided by a licensed health care provider.
Well Newborn Care
Well Newborn Care

The plan provides coverage for well newborn care furnished during the enrolled mother’s inpatient maternity stay: This coverage includes:

  • Pediatric care furnished by a plan provider (who is a pediatrician) or network nurse practitioner for a well newborn.
  • Routine circumcision furnished by a plan physician.
  • Newborn hearing screening tests performed by a plan provider before the newborn child (an infant under the three months age) is discharged from the hospital to the care of the parent or guardian or as provided by regulations of the Massachusetts Department of Public Health.

Note: See Adding dependents in How your coverage works section for coverage when an enrolled newborn child requires medically necessary inpatient care.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Routine maternity care when you are traveling outside the plan service area. This includes prenatal, delivery and admission, and postpartum care.
  2. Delivery outside the plan service area after the 37th week of pregnancy, or after you have been told that you are at risk for early delivery
  3. Routine circumcision performed after an infant’s discharge from a maternity hospital admission (unless determined to be medically necessary prior to discharge)
  4. Charges for a home birth
  5. Services provided by a lactation consultant are excluded.
  6. Services for a well newborn who has not been enrolled as a member, other than nursery charges for routine services provided to a well newborn.
  7. Any and all costs associated with any form of surrogacy, specifically including, but not limited to, costs of prenatal, delivery-related and postnatal professional and facility-related care of gestational carriers.
Mental health and substance abuse services
Mental health and substance abuse services

The plan covers the diagnosis and treatment of mental conditions on an outpatient and inpatient basis. A mental condition is defined as a condition that is described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association and that is determined as such by a plan provider and the plan. The level of care needed is authorized by a plan provider. Treatment may be provided by a psychiatrist, psychologist, psychotherapist, licensed nurse, mental health clinical specialist, licensed independent clinical social worker, mental health counselor, pediatric specialist, certified alcohol and drug abuse counselor or other provider as authorized by the plan.

For mental health and substance abuse emergencies, follow the same procedures as for any other medical emergency, as outlined in Emergency and urgent care.

Inpatient services
The plan covers mental health services in an inpatient setting, when authorized by the plan. To access services and obtain prior authorization, call 1-888-421-8861 (TDD/TTY: 1-781-994-7660). Unlimited coverage is provided for inpatient care when medically necessary in a licensed general hospital, a psychiatric hospital or a substance abuse facility (or its equivalent in an alternative program). Levels vary from least to most restrictive and include: respite or crisis stabilization; day or evening treatment or partial hospitalization; short-term residential treatment; and hospital-based programs.

Covered Services

  1. Inpatient hospital care for as many days as your condition requires, including room and board and the services and supplies that would ordinarily be furnished to you while you are an inpatient. These include, but are not limited to, individual, family and group therapy, pharmacological therapy, and diagnostic laboratory services.
  2. Professional services provided by physicians or other health care professionals for the treatment of mental conditions while you are an inpatient.

Intermediate services
Members may receive mental health care in an alternative setting in lieu of inpatient hospitalization.

Covered Services

  1. Acute and other residential treatment: Mental health services provided in a 24-hour setting therapeutic environments.
  2. Clinically managed detoxification services: 24 hour, 7 days a week, clinically managed de-tox services in a licensed non-hospital setting that include 24 hour per day supervision.
  3. Partial Hospitalization: Short-term day/evening mental health programming available 5 to 7 days per week.
  4. Intensive outpatient programs: Multimodal, inter-disciplinary, structured behavioral health treatment provided 2-3 hours per day, multiple days per week.
  5. Day treatment: Program encompasses some portion of the day or week rather than a weekly visit.
  6. Crisis Stabilization: Short-term psychiatric treatment in a structured, community based therapeutic environments.
  7. In-home therapy services
Outpatient services
Outpatient services

The plan covers services provided in person in an ambulatory care setting. Outpatient services may be provided in a licensed hospital, a mental health or substance abuse clinic licensed by the department of public health, a public community mental health center, or a professional office.

Members may self refer for outpatient mental health and substance abuse services. Any continuing services beyond eight sessions require prior authorization. For assistance in finding a plan provider, call 888-421-8861 (TDD/TTY: 1-781-994-7660). The plan covers medically necessary mental health and substance abuse services from a plan provider, in an outpatient setting, as follows:

Covered Services

  1. Outpatient office visits, including individual, group or family therapy. The actual number of visits authorized beyond the initial eight is based on medical necessity as determined by the plan, and may include individual, group, or family therapy.
  2. Psychopharmacological services, such as visits with a physician to review, monitor and adjust the levels of prescription medication to treat a mental condition
  3. Neuropsychological assessment services when medically necessary

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Mediation (dispute resolution) or intervention services
  2. Vocational evaluation, vocational counseling, vocational rehabilitation, and or vocational training
  3. Faith-based counseling (e.g., Christian counseling) or vocational counseling
  4. Services that do not include face-to-face participation by the member, such as “phone therapy”
  5. Residential halfway house services
  6. Acupuncture, biofeedback and biofeedback devices for home use, or any other alternative treatment for the treatment of a mental health or substance abuse condition.
  7. Services or programs that are not medically necessary for the treatment of a mental health or substance abuse condition. Some examples of services or programs that are not covered include (but are not limited to) at high-risk youth expeditions, outward bound-type programs, and wilderness programs.
  8. Services or programs that are provided in an educational, vocational or recreational setting.
  9. Services or programs that provide primarily custodial care.
Office visits and outpatient services
Office visits and outpatient services

The plan provides coverage for the covered services listed below. Coverage is provided on a nondiscriminatory basis for services delivered or arranged by a nurse practitioner. Pediatric specialty care, including mental health care, is covered when provided to a member requiring such services by a provider with recognized expertise in specialty pediatrics.

You may self-refer to your PCP. You may self-refer to any Reliant Medical Group specialist (physician, physician assistant, or nurse practitioner) if you have a Reliant Medical Group PCP. Specialty services with a specialist other than a Reliant Medical Group specialist generally require referral and prior authorization. See Obtaining specialty care and services for more information on referral and prior authorization.

The plan covers the costs for services furnished to members enrolled in certain qualified clinical trials to the same extent as they would be covered if the member did not receive care in a qualified clinical trial.

To be eligible for coverage, you must have been diagnosed with cancer and the clinical trial must be one that is intended to treat cancer. Coverage for services provided to you while you are enrolled in the clinical trial is subject to all the terms and conditions of the plan, including, but not limited to, provisions requiring the use of plan providers.

Covered Services

Office visits and related services

  1. Office visits, to diagnose or treat an illness or an injury
  2. A second opinion, upon your request, with another plan provider
  3. Injections and injectables that are included on the formulary, that are for covered medical benefits, and that are ordered, supplied and administered by a plan provider (requires prior authorization)
  4. Allergy injections
  5. Radiation therapy
  6. Respiratory therapy
  7. Hormone replacement services in the doctor’s office for perimenopausal or postmenopausal women
  8. Diagnostic lab and X-ray services

  9. Diagnostic lab and X-ray services ordered by a plan provider, in relation to a covered office visit
  10. Chiropractic services

  11. Chiropractic services for acute musculoskeletal conditions. The condition must be new or an acute exacerbation of a previous condition. Coverage is provided for up to 20 office visits in each calendar year, when medically necessary.
  12. Renal dialysis

  13. Outpatient renal dialysis at a plan-designated center or continuous ambulatory peritoneal dialysis. (Please see Medicare under The claims process section for more information.) Diabetic services
  14. Diabetes outpatient self-management training and education, including medical nutrition therapy, provided by a certified diabetes health care provider
  15. Laboratory tests necessary for the diagnosis or treatment of diabetes, including glycosylated hemoglobin, or HbA1c, tests, and urinary protein/ microalbumin and lipid profiles
  16. Medical social services

  17. Medical social services provided to assist you in adjustment to your or your family member’s illness. This includes assessment, counseling, consultation and assistance in accessing community resources.
  18. Outpatient (day) surgery

  19. Same-day surgery in a hospital outpatient department or ambulatory care facility
  20. Minute clinic (mini-clinics)

  21. Visit to a contracted limited service clinic. Services are provided for a variety of common illnesses, including, but not limited to:
    • strep throat
    • ear, eyes, sinus, bladder and bronchial infections
    • minor skin conditions (e.g. sunburn, cold sores)

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Services required by a third party or court order. Examples are employment, school, sports, premarital and/or summer camp examinations or tests, and any immunizations required by an employer, related to your job and/or work conditions.
  2. Alternative therapies (also known as complimentary and alternative medicine) including but not limited to acupuncture, biofeedback, massage therapy, craniosacral therapy, hippotherapy, etc.
  3. Visits to additional providers beyond a second opinion, or a second opinion with a non-plan provider unless approved in advance by the plan
  4. Laboratory tests to evaluate cardiovascular disease risk, such as Lipoprotein, The PLAC Test, NMR Lipoprofile.
Oral surgery
Oral surgery

The plan covers the oral surgery services listed below. All services must be provided by a plan oral surgeon or plan physician.

You do not need a plan referral or prior authorization for extraction of impacted teeth. All other oral surgery services require plan referral and prior authorization. See Obtaining specialty care and services for more information on plan referrals and prior authorization.

Covered Services

  1. Removal or exposure of impacted teeth, including both hard and soft tissue impactions, or an evaluation for this procedure
  2. Surgical treatments of cysts, affecting the teeth or gums, that must be rendered by a plan oral surgeon
  3. Surgical removal of benign or malignant lesions (includes cysts) affecting the intraoral cavity. Reconstruction of a ridge is covered when performed as a result of and at the same time as the surgical removal of a tumor.
  4. Treatment of fractures of the jawbone (mandible) or any facial bone
  5. Evaluation and surgery for the treatment of temporomandibular joint disorder when a medical condition is diagnosed, or for surgery related to the jaw or any structure connected to the jaw
  6. Lingual frenectomy
  7. Emergency medical care, such as to relieve pain and stop bleeding as a result of traumatic and/or accidental injury to sound natural teeth or tissues, when provided as soon as medically possible after the injury in the office of a physician, dentist or in a hospital emergency room. This does not include restorative or other dental services.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Procedures or services related to dental care.
  2. Dental treatments and appliances for the treatment of temporomandibular joint disorder (TMJ)
  3. Services that have not been authorized by the plan, or unauthorized services provided by a nonplan oral surgeon
  4. Dentures and the following procedures, when performed for the preparation of the mouth for dentures: removal of a torus palatinus, alveoplasty, frenectomy and reconstruction of a ridge
  5. Osseointegrated implants or insertion of a core-vent implant
  6. Covered services that are performed secondary to a noncovered service
  7. Insertion of a core-vent implant (a titanium prosthetic inserted for implantation into the maxillary ridges to provide suitable abutments for the replacement of missing teeth) to support dentures.
  8. Extractions due to decay or periodontal disease or extractions in preparation for dentures.
  9. Removal of nonimpacted wisdom teeth.
Organ transplants
Organ transplants

The plan covers certain human solid organ, bone marrow and stem cell transplants. For example, this includes but may not be limited to bone marrow transplant or transplants for persons who have been diagnosed with breast cancer that has progressed to metastatic disease.

If you are the recipient of a transplant, the services for the donor are covered, including the evaluation and the preparation, surgery and recovery directly related to the donation, except for those services covered by another insurer. If you are the donor and the transplant recipient is not a member of the plan, no coverage is provided for either the recipient or the donor.

The transplant must be performed at a contracted transplant facility, subject to your acceptance into the program. FHLAC will work with the transplant facility to coordinate your care during the evaluation and transplant process and help to arrange your discharge and follow-up care.

If you want a second opinion, FHLAC will identify another suitable transplant facility. Additional opinions beyond a second opinion are not covered. Transplant services require a referral from your PCP and prior authorization. (See Obtaining specialty care and services for more information.)

Covered Services

  1. Office visits related to the transplant
  2. Inpatient hospital services, including room and board in a semiprivate room (or private room if it is required based on medical necessity) and the services and supplies that would ordinarily be furnished to you while you are an inpatient*
  3. Professional services provided to you while you are an inpatient, including, but not limited to medical, surgical and psychiatric services
  4. Human leukocyte antigen (HLA) or histocompatability locus antigen testing for A, B or DR antigens, or any combination thereof, necessary to establish bone marrow transplant donor suitability of a member

* If your group has a copayment for inpatient admissions, the copayment will apply to each inpatient admission, including admissions for services related to organ transplants.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Experimental/investigational or unproven procedures, including but not limited to:
    • The transplant of partial pancreatic tissue or islet cells
    • A pancreatic transplant that does not follow a kidney transplant or that is not part of a combined pancreas-kidney transplant
  2. Bioartificial transplantation, such as the transplant of a total artificial heart
  3. Xenotransplantation, such as the transplant of animal tissues or organs into a human
  4. Services for the organ donor that are covered by another insurer
  5. Services for an organ donor if the recipient is not a member of the plan
  6. Transportation or housing costs for the recipient or donor
  7. House cleaning costs incurred in preparation for a transplant recipient’s discharge
Prescription medication
Prescription medication

The plan covers medically necessary prescription drugs according to the requirements and guidelines discussed below.

Who can write your prescription
A plan provider or a provider you have seen through an authorized referral can write your prescription.

Where you can fill your prescription
You can fill your prescription at a network pharmacy, a network mail-order pharmacy, or a network specialty pharmacy. (Please note that there are some medications that are not available through the mail-order program). Some medications may only be available through the network specialty pharmacy, and will only be available as a one-month supply at a time. See your FCHP Provider Network directory for a list of network pharmacies or visit fchp.org.

The FCHP formulary
The FCHP formulary is a list of medications covered by the health plan that shows the copayment tier, prior authorization requirements, and any other limitation for each medication. We have selected the tiers and determined the criteria for prior authorization based on the medication’s efficacy and costeffectiveness.

The FCHP prescription drug formulary has a multi-tiered copayment structure. We have selected the tiers based on efficacy and cost-effectiveness. There is a different copayment for each tier. A tier exception is not allowed.

Coverage of certain formulary medications is based on medical necessity. For these drugs, you will need prior authorization from the plan. They are noted on the formulary as “PA.” Your doctor should request prior authorization from the plan before he or she writes the prescription and give us the clinical information that we need to make our decision. We will review the prior authorization request according to our criteria for medical necessity.

The FCHP formulary may include drugs used for the off-label treatment of cancer or HIV/AIDS, in accordance with state law.

Dispensing limitations
Prescription drugs are generally dispensed for up to a 30-day supply. A one-month copayment will be charged for up to a 30-day supply. In some instances, the plan has established dispensing limitations,
which may include a quantity limit on certain medications. For maintenance medication, you may obtain up to a 90-day supply unless the medication must be obtained from the specialty vendor. We follow FDA, state and federal dispensing guidelines. You cannot obtain a refill until most or all of the previous supply has been used.

Please note: Your doctor may prescribe medication in a dose that is not available through the purchase of a single prescription. In these cases, you may need to fill more than one prescription and pay a copayment for each to achieve the desired dose.

Step-therapy
There are certain medications for which you will be required to have previously used certain other formulary medications. This is called step-therapy.

Step-therapy is a strategy where drugs for a given condition are dispensed using a logical sequence beginning with Step 1 drugs (most cost-effective) moving to Step 2 drugs (less cost-effective), based on accepted medical guidelines and standards.

Generic and brand-name drugs
A generic drug is a drug product that meets the approval of the U.S. Food and Drug Administration and is equivalent to a brand-name product in terms of quality and performance. It may differ in certain other characteristics (e.g., shape, flavor, or preservatives). By law, generic drug products must contain identical amounts of the same active drug ingredient as the brand-name product.

You will receive a generic drug from network pharmacies anytime one is available, unless your doctor has directed the pharmacist to only dispense a specific brand-name drug. However, some brandname drugs do not have a generic equivalent. In both these cases, you will receive the brand-name drug and will be responsible for the appropriate tiered copayment for that drug.

Mail-order prescriptions
You may also get your prescription medication refill(s) through a network pharmacy mail-order program. You may have your prescription mailed directly to you at home or at any other location if you are traveling within the country. Most medications can be mailed; however, there are some that may not. (Medications cannot be mailed to other countries.)

When you fill your prescription through our mail-order program, you may order up to a 90-day supply of most medications. You will be responsible for the appropriate copayment amount.

Medications required to be obtained from the network specialty pharmacy can only be obtained as a one-month supply at a time.

New members
If you are a new member and need to have an existing prescription refilled, we encourage you to see your PCP to review your prescriptions. If you are currently taking a drug that requires prior authorization by FCHP, your doctor will need to submit a request for prior authorization. We will determine coverage of that drug based on our criteria for medical necessity. If the drug you are currently taking is a higher-tier medication or a brand medication, you may want to discuss lower-tier or generic alternatives with your doctor.

Covered items (some of these medications and covered items may require prior authorization.)

  • Prescription medication
  • Prescription contraceptive drugs and devices
  • Hormone replacement therapy for per- and post- menopausal women
  • Injectable agents (self-administered*)
  • Insulin
  • Syringes (including insulin syringes) or needles when medically necessary
  • Supplies for the treatment of diabetes, as required by state law, including:
    • Blood glucose monitoring strips
    • Urine glucose strips
    • Lancets
    • Ketone strips

* Injectables administered in the doctor’s office or under other professional supervision are covered as a medical benefit.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Drugs that you can buy without a prescription, including prescription medications that are available as over-the-counter products unless included on the FCHP formulary
  2. Drugs that are investigational or that have not been approved for general sale and distribution by the U.S. Food and Drug Administration
  3. Drugs that are not used in accordance with FDA-approved labeling, including, but not limited to: unapproved doses, unapproved duration of therapy and unapproved indications
  4. Drugs that require prior authorization, if prior authorization is not received
  5. Drugs prescribed for purposes that are not medically necessary. This includes, but is not limited to, drugs for cosmetic purposes, to enhance athletic performance, for appetite suppression, or for other non-covered conditions. This also includes drugs that do not meet medical criteria. Cosmetic includes, but is not limited to, melasma, vitiligo, and alopecia.
  6. Prescriptions obtained at a non-network pharmacy
  7. Non-emergency prescriptions filled outside the plan service area
  8. Vitamins and minerals, whether or not a prescription is required, are excluded from coverage, unless listed in the FCHP drug formulary or under the Oh Baby! program.
  9. Over-the-counter birth control preparations or devices
  10. Drugs that are prescribed for anything other than the U.S. Food and Drug Administration’s approved usage. (This does not include the off-label uses of covered prescription drugs used in the treatment of HIV/AIDS or cancer when used in accordance with state law. This also does not include bone marrow transplants for breast cancer as required by state law.)
  11. Medications used for preference or convenience
  12. Medications that are new to the market that have not been reviewed by FCHP for safety and adverse events. These medications are not covered by FCHP until they have been reviewed and guidelines for their use have been developed. This could take up to 180 days post-marketing.
  13. Replacement of more than one lost/mishandled medication per calendar year
  14. Prescription drugs that are a combination of a covered prescription item and an item that is specifically excluded, such as vitamins, minerals, or medical foods
  15. Bio-identical hormone replacement therapy.
  16. The following Proton Pump Inhibitors: Prevacid®, lansoprazole, Protonix®, pantoprazole, Zegerid®, omeprazole, Prilosec® and others not on the FCHP formulary
  17. Drugs that are specifically excluded from the formulary
  18. Copayment tier exceptions
  19. The following are not covered benefits:
    • Topical acne combination products
    • Topical emollients
    • Medical wound dressings for maintenance or long term care of a condition
    • Work-required vaccines
  20. The following non-sedating antihistamines: Allegra®, Allegra ODT®, Cetirizine HCl, Clarinex®, Claritin®, Claritin Reditabs®, Fexofenadine HCl, Xyzal and Zyrtec®
  21. Vimovo
Preventive care
Preventive care

The plan covers preventive services under the United States Preventive Services Task Force (USPSTF), Health Resources and Services Administration (HRSA) and the Advisory Committee on Immunization Practices of the Centers of Disease Control and Prevention (ACIP) as required by the Patient Protection and Affordable Care Act of 2010. In addition to the services listed in this section, you may visit our Web site at fchp.org for more information on these guidelines.

Covered Services

  1. Routine physical exams for the prevention and detection of disease
  2. Immunizations that are included on the FCHP formulary, that are for covered medical benefits and that are ordered, supplied and administered by a plan physician. If administered by a plan specialist, you will generally need to obtain a referral to see the specialist
  3. A baseline mammogram for women age 35 to 40, and a yearly mammogram for women age 40 and older
  4. Routine gynecological care services, including an annual Pap smear (cytological screening) and pelvic exam
  5. Hearing and vision screening
  6. Well-child care and pediatric services, at least six times during the child’s first year after birth, at least three times during the next year, then at least annually until the child’s sixth birthday. This includes the following services, as recommended by the physician and in accordance with state law:
    • Physical examination
    • History
    • Measurements
    • Sensory screening
    • Neuropsychiatric evaluation
    • Development screening and assessment
  7. Pediatric services including:
    • Appropriate immunizations
    • Hereditary and metabolic screening at birth
    • Newborn hearing screening test performed before the newborn infant is discharged from the hospital or birthing center
    • Tuberculin tests, hematocrit, hemoglobin, and other appropriate blood tests and urinalysis
    • Lead screening
  8. Voluntary family planning
  9. Consultations, examinations, procedures and medical services related to the use of all contraceptive methods
  10. Contraceptive devices that are supplied by an FCHP Direct Care network provider during an office visit

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Routine eye examinations
  2. Fittings for contact lenses
  3. Eyeglasses or contact lenses
  4. Laser vision correction surgery
  5. Vision therapy or services (also referred to as orthoptics)
  6. Services required by a third party or court order. Examples are employment, school, sports, premarital and/or summer camp examinations or tests, and any immunizations required by an employer, that are related to your job and/or work conditions.
Reconstructive and restorative services
Reconstructive and restorative services

The plan covers reconstructive services to improve or correct a physical functional impairment resulting from a congenital defect or birth abnormality, accidental injury, prior surgical procedure or disease.

The plan covers restorative services to repair or restore appearance damaged by accidental injury. Only the initial repair is covered.

Services performed to improve appearance in the absence of any signs and or symptoms of physical functional impairment, are considered cosmetic and are not covered (with the exception of services performed to repair or restore appearance after accidental injury). Services required to treat a complication that arises as a result of a prior non-covered surgery/procedure, may be covered when medically necessary in all other respects.

In accordance with the Women’s Health & Cancer Rights Act of 1998, coverage is provided for reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and physical complications of all stages of mastectomy, including lymphadema.

You may self-refer to a Reliant Medical Group specialist if you have a Reliant Medical Group PCP.

Services with a non-Reliant Medical Group specialist require referral and prior authorization. Your surgeon must obtain prior authorization from FHLAC for all procedures. See Obtaining specialty care and services for more information on referrals and prior authorization.

Reconstructive and restorative surgery are subject to inpatient and outpatient cost sharing amounts and exclusions.

Covered services

  1. Office visits related to covered reconstructive and restorative services
  2. Inpatient hospital services including room and board in a semiprivate room and the services and supplies that would ordinarily be furnished to you while you are an inpatient
  3. Professional services provided to you while you are an inpatient, including, but not limited to medical, surgical and psychiatric services

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Cosmetic surgery, cosmetic treatments, cosmetic procedures, cosmetic medications and cosmetic supplies, including, but not limited to: otoplasty for protruding ears; ear piercing; abdominoplasty; chemical peel (dermal and epidermal); microdermabrasion; and hair removal.
  2. Services related to cosmetic surgery, cosmetic treatments, and cosmetic procedures are not covered. This includes but is not limited to: physician charges, hospital charges, charges for anesthesia, drugs, etc.
  3. Care of the teeth and supporting structures, including reconstructive, major restorative or cosmetic dental services, such as dental implants (also known as osseointegrated or titanium implants), dentures, crowns, and orthodontics. Care of the teeth and supporting structures is not covered, even when part of a covered medical procedure, such as a cleft lip/palate repair. Similarly, medical or surgical procedures in preparation for a dental procedure are also not covered (for example, a bone graft to prepare for a dental implant).
  4. Services related to gender reassignment or the reversal of gender reassignment.
  5. Services for the treatment of snoring.
  6. Removal of breast implant except when determined to be medically necessary by FHLAC. Even when removal of a breast is covered, reinsertion of a replacement breast implant is considered cosmetic and is not covered (except for plan members who elected reconstruction following mastectomy).
  7. Liposuction, also known as suction lipectomy or suction assisted lipectomy, is the surgical excision of subcutaneous fatty tissue. Liposuction (CPT codes 15876-15879) is not covered. However, liposuction is an integral part of certain covered services, such as the surgical removal of excessive skin (CPT codes 15830-15839), but is not separately reimbursed.
  8. Treatments for acne scarring including, but not limited to subcutaneous injections to raise acne scars, chemical exfoliation (CPT 17360), and dermabrasion.
  9. The following treatments for active acne are not covered: acne surgery (CPT code 10040), cryotherapy for acne (CPT code 17340), chemical exfoliation for acne (CPT code 17360), and laser and light-based therapies, including but not limited, to blue light therapy, pulsed light, and diode laser treatment.
  10. Custom breast prosthesis.
Rehabilitation services
Rehabilitation services

The plan covers outpatient rehabilitation services. Services must be medically necessary, ordered by a plan physician and provided by a plan provider. Short-term rehabilitation services, such as physical,
occupational, and speech therapy, are covered for up to 60 visits per illness or injury per calendar year. Medical necessity determines the actual number of visits covered.

Services require referral. See Obtaining specialty care and services for more information on referrals.

Covered services

  1. Physical therapy to restore function after medical illness, accident or injury. Coverage is provided for up to 60 non-consecutive office visits per illness or injury in each calendar year when medically necessary.
  2. Occupational therapy to restore function after medical illness, accident or injury. Coverage is provided for up to 60 non-consecutive office visits per illness or injury in each calendar year when medically necessary.
  3. Medically necessary services for the diagnosis and treatment of speech, hearing and language disorders when services are provided by an FCHP provider who is a speech-language pathologist or audiologist; and at an FCHP provider facility or FCHP provider’s office. Speech therapy requires prior authorization. Coverage is provided for up to 60 non-consecutive office visits per illness or injury in each calendar year when medically necessary.
  4. Cardiac rehabilitation services to treat cardiovascular disease in accordance with state law and Department of Public Health regulations
  5. Medically necessary early intervention services delivered by certified early intervention specialists, according to operational standards developed by the Department of Public Health, for children from birth to their third birthday. Benefits are limited to a maximum of $5,200 per calendar year per child and an aggregate benefit of $15,600 over the term of the child’s plan membership.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Long-term rehabilitation services
  2. Maintenance treatment or services
  3. Services for non-acute chronic conditions. Chronic conditions are those that exist for an extended time or continue past the expected recovery time for acute or short-term conditions. For example, the plan defines chronic pain as continuing for more than three months after the injury or illness causing the original pain.
  4. Services that are not determined to be medically necessary. This applies even if the plan limits have not yet been reached.
  5. Services that are not medically necessary, including but not limited to, acupuncture, biofeedback, hippotherapy, and massage therapy.
  6. Educational services or testing, except services covered under the benefit for early intervention services as described above.
Inpatient acute rehabilitation services
Inpatient acute rehabilitation services

Acute inpatient rehabilitation services, whether provided in the setting of a hospital or a distinct unit, provide an intense program of coordinated and integrated medical and rehabilitative care. The practitioners who comprise the interdisciplinary team have special training and experience in evaluating, diagnosing, and treating persons with limited function as a consequence of diseases, injuries, impairments, or disabilities. Further, acute inpatient rehabilitation care is provided to patients who are at high risk of potential medical instability, have a potential for needing skilled nursing care of a high medical acuity, and require a coordination of services, level of intensity and setting as follows:

  • Regular, direct individual contact by a physiatrist or physician of equivalent training and/or experience in rehabilitation who serves as their lead provider;
  • Daily rehabilitation nursing for multiple and/or complex needs;
  • A minimum of three hours of physical or occupational therapy per day, at least five days per week, in addition to therapies or services from a psychologist, a social worker, a speech-language pathologist, and a therapeutic recreation specialist, as determined by their individual needs; and
  • Based on their individual needs, other services provided in a health care facility that is licensed as a hospital.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Chronic rehabilitation services
  2. Services beyond 100 days in each calendar year
  3. Services that are not deemed to be medically necessary, even if the plan limit of 100 days per calendar year has not been reached
Skilled Nursing Facility
Skilled nursing facility

The plan covers inpatient services in a plan skilled nursing facility for up to 100 days in each calendar year, provided criteria are met.

You may be admitted to a skilled nursing facility if, based on your medical condition, you need daily skilled nursing care, skilled rehabilitation services or other medical services that may require access to 24-hour medical or nursing care but does not require the specialized care of an acute care hospital.

Services require referral and prior authorization. See Obtaining specialty care and services for more information on referrals and prior authorization. The level of services, number of covered days that you are admitted and where you are admitted will be based upon the medical necessity of your condition as determined by your plan physician and the plan.

Covered services (see Inpatient services for more details.)

  1. Room and board in a semiprivate room (or private room if medically necessary), for up to 100 days in each calendar year, provided criteria are met
  2. The services and supplies that would ordinarily be furnished to you while you are an inpatient. These include, but are not limited to, nursing services, physical, speech and occupational therapy, medical supplies and equipment.
  3. Physician services

Related exclusions (please see Inpatient services and general exclusions and limitations for more details.)

  1. Services beyond 100 days in each calendar year
  2. Services that are not determined to be medically necessary, even if the plan limit of 100 days per calendar year has not yet been reached
  3. Rest care or long-term care
Special Formulas
Special formulas

The plan covers the special medical formulas and food products listed below. Except for these items, the plan does not cover any nutritional formulas, supplements or food products.

Covered formula and food items require referral and prior authorization. See Obtaining specialty care and services for more information on referrals and prior authorization.

Covered services

  1. Special medical formulas to treat certain metabolic disorders as required by state law. Metabolic disorders covered under state law include: phenylketonuria, tyrosinemia; homocystinuria; maple syrup urine disease; propionic acidemia; and methylmalonic acidemia in a dependent child, including when medically necessary to protect unborn fetuses of pregnant women with phenylketonuria.
  2. Enteral formulas, upon a physician’s written order, for home use in the treatment of malabsorption caused by Crohn’s disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids
  3. Food products that have been modified to be low in protein for individuals with inherited diseases of amino acids and organic acids. Coverage is provided for up to $2,500 per member in each calendar year. You may be required to purchase these products over the counter and submit claims to the plan for reimbursement.

Related exclusions (please see General exclusions and limitations for additional limitations)

  1. Nutritional supplements, medical foods and formulas unless described above as covered
  2. Dietary supplements, specialized infant formulas (such as Nutramigen, Elecare and Neocate), vitamins and/or minerals taken orally to replace intolerable foods, supplement a deficient diet, or provide alternative nutrition for conditions such as hypoglycemia, allergies, obesity and gastrointestinal disorders. These products are not covered even if they are required to maintain weight or strength.