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Health Fund

Looking At Eligible And Ineligible Medical Expenses

Eligible Expenses

The PPO Plan (including out-of-area benefits) and Low Option Plan cover a wide range of services, including those described below. If you want to know whether a particular service is covered, contact the Administrative Office.

Once you satisfy the deductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits., the Fund will pay a percentage of charges for medically necessaryMedical treatment that satisfies the definition of "necessary treatment." expenses required to treat an illnessA sickness or disease that causes loss covered by the plan. Pregnancy is considered a sickness with respect to a covered female participant, the Same-Sex Domestic Partner of a female covered participant and the spouse of a male covered participant only. Pregnancy for dependent children isn't covered, except for complications of pregnancy. or injuryBodily harm caused by an accident. The injury must also result, for the purposes of accidental death and dismemberment coverage, directly and independently of all other causes, in a loss covered by the plan.. The percentage will depend on whether you see a network or non-network provider, or whether you live outside the network area. (For details, see the Summary Of Benefits starting on page 6.)

eligible expensesAny reasonable and customary charge for medically necessary services or supplies which is cove red in full or in part by the plan.appear in alphabetical order. This list includes most, but not all, eligible expenses. Expenses are eligible only if medically necessary and not more than the network allowances or the reasonable and customary R&CReasonable and Customary Charge - The fee regularly charged and received for a given service by the health care provider which doesn't exceed the general level of charges, as determined by the Fund, being made by providers of similar training and experience for treatment of a similar sickness, condition or injury in a similar geographic area. To determine an R&C charge, physicians are surveyed by region to determine what they will accept as payment for each procedure. That data is organized in percentile groups - the Fund uses the 80th percentile to determine R&C charges. limits.


All alternative therapy, claims are subject to review for medical necessity at time of payment. See the section to the right for the services that require a referral from an M.D.

Alternative Medical Benefit

Benefits for therapy provided by a "covered provider" are covered for the following services and therapies:

* A referral is required from an M.D.

The Fund allows up to $60 per day, payable at the in or out-of-network coinsurance level.

What is a "Covered Provider"?

For the purposes of the alternative medical benefit, the Fund will consider services provided by the following licensed providers acting within the scope of their license:

  • Certified Acupuncturist;
  • Doctor of Chiropractic;
  • Doctor of Medicine;
  • Doctor of Oriental Medicine (only acupuncture treatments are covered);
  • Doctor of Osteopathy;
  • Registered Occupational Therapist; and
  • Registered Physical Therapist;

Ambulatory Surgical Center

An Ambulatory Surgical Center must have permanent facilities and be equipped and operated primarily for the purpose of performing surgical procedures and must be Medicare-certified or State-licensed as an ambulatory surgical facility, or have certification from a private accreditation agency accepted by the State in lieu of state licensure.

The type of procedures performed must permit discharge from the center on the same working day. In-network Ambulatory Surgical Center charges will be based on the network contracted allowances. Out-of-network Ambulatory Surgical Center charges will be reimbursed up to a maximum payment of $1,500 if all of the conditions for coverage described here are met. Any applicable deductibles and coinsuranceThe percentage of eligible expenses you're responsible for paying. will apply.

Birthing Centers

A birthing center is a facility established to manage low risk, normal, uncomplicated pregnancy with delivery within 24 hours of admission to the center. It must be licensed by the State (if required by the State) as a birthing center.

As an alternative to traditional hospital delivery of a child, the Plan pays benefits for the following services provided by a birthing center:

  • Pre-natal care;
  • Use of the birthing room;
  • Services rendered during delivery, including the first 48 hours of follow-up care;
  • Care for the newborn and post-partum care of the mother;
  • Routine nursery care;
  • Services of a midwife under the supervision of a medical doctor.
Contact Lenses Or Eyeglasses - Post Cataract Surgery

The first pair of contact lenses or eyeglasses that are required within six months after cataract surgery are covered as a medical benefit.


Various forms of contraception are covered by the Health Fund. Some forms are covered under medical benefits and some under prescription drug benefits (see Prescription Drug Benefits section beginning on page 55 for more information), as follows:

  • Depo-Provera, IUDs and Norplant are covered under the prescription drug benefits. These devices are covered under the prescription drug benefits if purchased at a retail pharmacy or mail-order services. Otherwise they are covered under medical benefits;
  • Vasectomies and tubal ligations are covered under medical benefits; and
  • Diaphragms and birth control pills are covered under prescription drug benefits.

Note:  Effective January 1, 2013, the Fund will cover approved women's contraceptive methods under the Preventive Care Benefits at 100% with no deductible or copayment if rendered by an in-network provider in accordance with the applicable requirements under PPACA (PPO and Low Option Plans). (See page 72 of the SPD for details as to what contraceptive methods are covered under this rule.)

Emergency Room Services

The Fund will charge you the same copayment or coinsurance for hospital emergency room services whether you obtain those services from a participating in-network hospital or from a non-participating out-of-network hospital. Accordingly, emergency care provided in an emergency room by an out-of-network provider will be considered at the network coinsurance level or 85% for the PPO Plan and 70% for the Low Option Plan, subject to the Fund's $50 copayment* and annual deductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits.. However, if you obtain those services from a non-participating out-of-network hospital, that hospital may bill you separately if the hospital's charges exceed the Fund's allowances for the services. Coverage for the emergency room services at the network coinsurance rate must meet the definition of emergency care as noted on page 48.

* Copay is waived if admitted; hospital admission copay applies.

Elective Surgery - Network Second Opinion

Services from a physician and diagnostic X-ray and laboratory services in connection with one second opinion per surgery are covered when the physician recommends non-emergency elective surgery and when the services are coordinated through the Plan's network. If the second opinion confirms the first, the Fund will pay a percentage of the primary surgeon's R&CReasonable and Customary Charge - The fee regularly charged and received for a given service by the health care provider which doesn't exceed the general level of charges, as determined by the Fund, being made by providers of similar training and experience for treatment of a similar sickness, condition or injury in a similar geographic area. To determine an R&C charge, physicians are surveyed by region to determine what they will accept as payment for each procedure. That data is organized in percentile groups - the Fund uses the 80th percentile to determine R&C charges. charges over and above what it would otherwise pay.

Enhanced External Counterpulsation (EECP) Therapy

EECP therapy is covered. (See the Summary Of Benefits page 10 for details.)

Home Health Care (Preauthorization Required)*

Home Health careA program for care and treatment of a sick or injured person in that person's home by a home health care agency. The program must be ordered by the sick or injured person's attending physician and approved by case management intervention. services are provided to individuals who are considered to be home-bound. These services are covered when they are ordered by your physician and reviewed by the Fund's Utilization Administrator. Intermittent services include physical, occupational or speech therapy or nursing care provided by a licensed provider (R.N., L.P.N, or L.V.N.).

To be considered for coverage, home health care must be:

Home Infusion Therapy ( PreauthorizationPreauthorization, sometimes referred to as “pre-certification,” is the process used to confirm if a proposed service or procedure is a medically necessary health care service. Preauthorization, when required, should occur before treatment is received, except in an emergency. Required)*

Home infusion care (i.e., the administration of medication in the home setting as an alternative to hospitalization) is covered when your physician and the Fund's Utilization Administrator have determined it is medically appropriate for your condition and a licensed health care professional provides the service.

Examples of home infusion therapy include:

  • Central line care and maintenance;
  • Chemotherapy;
  • Drug therapy (such as antibiotics or antivirals);
  • Hydration therapy (with fluids, electrolytes and other additives);
  • Pain management; and
  • Total Parenteral Nutrition (TPN).
Hospice (Preauthorization Required)*

A covered person is eligible for hospice if his/her physician has determined that the patient has a medical prognosis of six months or less to live. HospiceAn agency that provides health care services for palliative treatment and supportive care of terminally ill individuals. Services may include medical social services, skilled RN visits, intermittent visits by a nursing assistant, all equipment needed for the comfort and care of the patient, pain management, therapy needed to maintain function and pastoral counseling. The agency that provides this service must: provide on-call coverage 24 hours a day, 7 days a week; provide a program of services under direct supervision of a physician or licensed R.N.; maintain full and complete records of all services provided to all covered persons; and be established and operated in accordance with the applicable laws or regulations of the jurisdiction in which it is located. programs enable terminally ill patients to remain in the familiar surroundings of their home for as long as they are able. Most terminally ill patients can be adequately treated using outpatient home hospice, but inpatient hospice is also an option. The patient, the family and the attending physician must all agree that medical treatment that aggressively prolongs life, including artificial life support systems, will no longer be used.

Services covered by the hospice program include:

  • Home visits by nurses and social workers;
  • Instruction and supervision of caregivers;
  • Pain management and symptom control;
  • Counseling and emotional support;
  • Rental of all equipment needed for care in the home, such as a hospital bed or bedside commode; and
  • Any other services required for the patient's comfort.

The Fund's Utilization Administrator will confirm that the physician, the patient and the family agree to use the hospice benefit and will make the referral to a participating hospice provider. Respite care for short-term temporary relief of the primary caregiver and/or family may be available through Case ManagementA program offered by the Fund which provides participants assistance, coordination and management of medical care and treatment..

* Please have your provider contact the Fund's Utilization Administrator to facilitate your care through Case Management Intervention. On the backside of your Medical ID card, you will find the phone number for PreAuthorization or Pre-Service Review.

Hospital, Surgical, Medical

All plans cover the following at the applicable network or non-network level:

  • Artificial limbs and eyes;
  • Cardiac rehabilitation for medically necessary treatments, including angioplasty and valvoplasty procedures;
  • Charges for fitting or purchasing hearing aids or devices, subject to limitations (see the Summary of Benefits, page 10, for details);
  • Charges for room, board and staff nursing services generally provided in an inpatient setting. These charges will be considered up to the semi-private room rate;
  • Collection, processing and storage of self-donated blood when collected for a planned and covered surgical procedure;
  • Electrocardiograms;
  • Emergency air or sea ambulance, when approved by the Fund's Medical Consultant, subject to limitations (see the Summary Of Benefits, page 9, for details);
  • Emergency ground ambulance transfer to the nearest hospital;
  • Emergency medical care;
  • Hydrotherapy;
  • In-hospital/ambulatory center prescription medication and oxygen (excluding take-home medication);
  • Inpatient rehabilitative therapy provided at a comprehensive medical rehabilitation hospital (acute rehabilitation facility), provided that case management reviews the placement, and:
    • The patient has a condition that results in a significant decrease in functional ability;
    • There is a reasonable expectation that the patient will improve in a reasonable and generally predictable period of time and that such recovery will be aided by the inpatient rehabilitation care;
    • The intensity of service required cannot be provided in a lower intensity setting;
    • The patient requires and will receive multidisciplinary team care, defined as at least two therapies (i.e., speech, occupational, physical, and/or respiratory therapies) provided at least three times per day, five days per week; and
    • The patient's medical condition and treatment require physician supervision at least three times per week;
  • Intensive care unitA section within a hospital which operates exclusively for the care of critically ill patients and which provides special supplies, equipment and constant observation and care by registered nurses or other highly trained hospital personnel. It is not a hospital facility maintained for the purpose of providing normal postoperative recovery treatment. or similar care unit;
  • Laboratory, X-ray and diagnostic tests;
  • Maternity and newborn infant coverage. Benefits for any hospital stay in connection with childbirth for the mother or newborn child will be provided for a minimum of 48 hours for the mother and infant after a normal vaginal delivery and for a minimum of 96 hours after a Caesarean section;
  • Ordinary casts, splints, dressings and crutches;
  • Outpatient hospital/ambulatory center care and treatment;
  • Oxygen and rental of equipment for giving oxygen for medically appropriate patients based on the following guidelines as determined by Medicare:
    • Chronic lung disease, such as chronic obstructive pulmonary disease, interstitial fibrosis, bronchiectasis, cystic fibrosis or cancer; and
    • Hypoxemia at rest, with exercise or during sleep;
  • Physical therapy as described under "Alternative Medical Benefit";
  • Physician care within or outside the hospital;
  • Rental of durable medical equipmentEquipment that is: ordered by your physician; used primarily for medical purposes; able to withstand repeated use; generally not of use in the absence of sickness or injury; and appropriate for use in the home. (DME), including manually or power-operated wheelchairs, or semi-electric hospital-type beds used in the patient's home. If the rental lasts more than one month, the monthly rental rate will be paid until the sum of all payments equals the purchase price. At this point, no further rental payments will be covered; DME is subject to medical necessity review and authorization of services.
  • Screening colonoscopies;
  • Services of surgeons, assistant surgeons, anesthesiologists and other specialists;
  • Services related to a hospital/ambulatory center;
  • Surgical and anesthetic supplies;
  • Testing and short-term storage of umbilical cord blood when a participant is undergoing treatment for which the use of umbilical cord blood stem cells is a viable alternative treatment to conventional allogeneic bone marrow transplant;
  • Use of operating and cystoscopic rooms; and
  • X-ray, radium and radioisotope therapy.
Inversion Device

The rental or purchase of an inversion device is covered if a physician prescribes the device as a treatment for chronic back problems. Documentation of at least six months of prior medical treatment is required.

Off-Label Drug Use

Off-Label Drug Use will be considered medically necessaryMedical treatment that satisfies the definition of "necessary treatment." when all of the following conditions are met:

  • The drug is approved by the United States Food and Drug Administration;
  • The drug is recognized by the American Hospital Formulary Service Drug Information, the U.S. Pharmacopoeia Dispensing Information, Vol. 1, or two articles from major peer-reviewed journals that have validated and uncontested data supporting the proposed use for the specific medical condition as safe and effective; and
  • The drug is medically necessary to treat the specific medical condition, including life-threatening conditions or chronic and seriously debilitating conditions.

If the off-label use is determined to be medically necessaryMedical treatment that satisfies the definition of "necessary treatment.", its use shall also be determined to be "non-investigational" for the purposes of benefit determination.

This policy shall not be construed to be required coverage for any drug when the United States Food and Drug Administration has determined its use to be contraindicated.

Please refer to the definition of medically necessaryMedical treatment that satisfies the definition of "necessary treatment." on page 129.

Organ And Tissue Transplants (Preauthorization Required)*

Organ aand tissue transplants must be preauthorized to be eligible for coverage. If preauthorization is not received, coverage will be denied.

The following organ and tissue transplants are eligible for coverage:

  • Bone transplants;
  • Corneal transplants;
  • Heart-lung transplants;
  • Heart transplants;
  • Intestine transplants;
  • Kidney-renal transplants;
  • Kidney-pancreas transplants;
  • Knee chondrocyte transplants;
  • Liver transplants;
  • Lung transplants;
  • Pancreas transplants;
  • Stem cell transplants.
  • Bone marrow transplants, either autologous or allogenic.

Each transplant case will be reviewed by the Fund's Utilization Administrator. Case Management will review the data and recommendations before treatment begins to determine whether the proposed treatment is investigational and/or medically necessary.

If preauthorization of an organ or tissue transplant is denied by the Fund or the Fund's Utilization Administrator and the organ or tissue transplant is one that could be eligible for coverage in appropriate cases, the denial may be appealed in accordance with the Fund's appeals procedures as described on page 105. The final decision regarding coverage will be made at the sole discretion of the Benefits Committee (or its delegate), which will base its determination in part on current peer-reviewed medical literature and guidelines issued by appropriate medical societies. All transplants will be reviewed on a case-by-case basis.

If your transplant surgery is approved and donor expenses are involved and the donor has no coverage under his or her medical insurance plan for donor expenses, the Health Plan will cover the donor's expenses (subject to the limitations noted below). Written documentation from the donor's insurance plan evidencing that donor expenses are not covered under the donor's plan is required.

Coverage of expenses for the donor will be limited to the surgical removal of the organ or tissue, related in-patient hospitalization, and storage and transportation of the organ or tissue, not to exceed the dollar limitation established by the Fund for the procedure performed. Also, donor expenses will be covered only if the procedures are performed by, and the expenses are incurred at, a network provider. If you are the transplant recipient, donor expenses will be processed under your claim file and will be subject to the same level of copayments, coinsurance, deductibles, and maximums that apply to you You (the recipient of the donated organ or tissue) are responsible for the amount of any donor expenses not covered by the Fund. For example, if you are in the PPO Plan and the donor has the organ removal performed by a network physician at a network facility, the Fund will pay 85% of the donor expenses, and you will be responsible for the remaining 15% (plus any applicable copays, deductibles, etc.).

* Please have your provider contact the Fund's Utilization Administrator to facilitate your care through Case Management Intervention. On the backside of your medical ID card, you will find the phone number for Preauthorization or Pre-Service Review.

Preauthorization - Inpatient and Outpatient Facility Expenses

To receive the highest level of benefits for inpatient and outpatient facility expenses, you need to see a network provider, who will work with Blue Cross/Blue Card to preauthorize your care. It is your responsibility, however, to first call Blue Cross/Blue Card to verify that the provider is in the network. You must also make sure the provider preauthorized your initial and ongoing care, which must be considered medically necessary in order to be authorized by Blue Cross/Blue Card.

PreauthorizationPreauthorization, sometimes referred to as “pre-certification,” is the process used to confirm if a proposed service or procedure is a medically necessary health care service. Preauthorization, when required, should occur before treatment is received, except in an emergency. is required for:

  • All in-network and out of network inpatient admissions; and
  • All in-network and out of network outpatient facilities. (Facility includes Residential, Partial hospitalization and Intensive Outpatient Programs)

If you do not preauthorize your care, your claim will be subject to a post-admission medical necessity review, which may delay the processing of your claim.

Preauthorization for inpatient or outpatient facilities should be obtained 7 to 10 days in advance by calling Blue Cross/Blue Card.* This includes any facility-based treatment, such as inpatient hospitalization, rehabilitation and residential treatment, or partial hospitalization and intensive outpatient programs for all conditions.

If you are admitted to the hospital or other facility because you have an emergency, you must preauthorize within 48 hours (or two business days) of your admission by calling Blue Cross/Blue Card. Your case will be assigned to a team of Clinical Care Managers.

* Please have your provider contact the Fund's Utilization Administrator to facilitate your care through Case Management Intervention.
On the backside of your medical ID card, you will find the phone number for Preauthorization or Pre-Service Review.

Physician Care

The Health Plan provides coverage for the following physician care (in-hospital or out-of-hospital):

  • Home, office and hospital visits; and
  • Services of physicians, surgeons and assistant surgeons, including specialists.

The allowance for a physician assistant surgeon will not exceed 20% of the allowance for the procedure.

The allowance for assistant surgery services by a physician assistant or other paramedical personnel permitted to assist at surgery under state regulation will be no more than 10% of the allowance for the procedure, except if determined otherwise by in-network pricing.

The use of an assistant surgeon must be medically necessary. An assistant surgeon is considered medically necessary when a procedure is at a level of technical surgical complexity that the assistance of another surgeon is required.

Services of operating room technicians are included in the surgeon or operating room facility charges and are not eligible for separate benefits.

If multiple surgical procedures are performed through the same incision, benefits will be based on the primary procedure. If two or more surgical procedures are performed through separate incision, the primary procedure will be considered up to 100% of the allowable charges and 50% of the allowable charges for the remaining procedures. No additional allowance will be given for those procedure considered incidental or non-covered.

Preventive Care Services

The Health Plan will cover certain preventive care services at 100% with no deductible or co-payment if they are rendered by an in-network provider.

The preventive services to which this new rule applies is generally defined to include the following, and may be amended from time to time:

  • Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventative Services Task Force ("Task Force") with respect to the individual involved.
  • Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in guidelines supported by the Health Resources and Services Administration (HRSA).
  • With respect to women, evidence-informed preventive care and screening provided for in the comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force).

Pages 70–72 contain a list of preventive care services that are currently covered at this level under the Plan, but this will change automatically as the above guidelines/recommendations change.

Many of the tests and screenings listed on these charts are already covered under the Plan's wellness benefits. There are certain wellness services that are not deemed to be preventive care services and, therefore, will continue to be covered under the Plan's Wellness Benefit Program. Accordingly, the Fund will apply the preventive care benefits first and any remaining wellness benefits (that do not constitute preventive care services) will be applied toward the Plan's $500/person or $1500/family annual wellness benefits.

Note: Cost Sharing When Preventive Care Services Are Provided as Part of an Office Visit*:

Generally speaking, the imposition of a cost-sharing requirement for office visits* during which recommended preventive health care services are rendered, either in whole or in part, depends upon how the preventive health service is billed and the primary nature of the office visit. Cost sharing for office visits will be applied if: (1) a preventive service is billed separately (or is tracked as individual encounter data separately) from an office visit where the primary purpose of the visit was for preventive services; or (2) the primary purpose of the office visit was not to provide a preventive service or item, regardless of whether preventive services are billed separately (or are tracked as individual encounter data) from an office visit.

Cost sharing for office visits* will not be applied if recommended preventive services are not billed separately (or are tracked as individual encounter data) from an office visit and the primary purpose of the visit was the delivery of a preventive service or item.

Also, there may be times when you are seen by your doctor for your annual physical examination, but your doctor may order several tests. Some of those tests may be considered preventive care. These tests will be paid at 100% of the network contract allowance only if in-network. Some of the tests ordered by your doctor might not be for preventive services and may be subject to any applicable deductibles, co-pays, or co-insurance. For example, if you go to a network provider for a sore throat and while there it is recommended that you have your cholesterol checked, the office visit is subject to the deductible/co-pay/coinsurance, and the cholesterol test is paid at 100%. Additionally, if you are diagnosed with a condition such as hyperlipidemia (high cholesterol) and your doctor performs a cholesterol test, then that test is subject to cost sharing as it is in connection with a medical condition, and not preventive services. Please also note that the Fund will only pay for preventive services which are considered medically necessary. For example, a routine colonoscopy for an individual under the age of 50 would not be a covered expense as this test is performed routinely only for individuals age 50 and over.

*The office visit rules stated above will apply to facility charges and it may not include all associated services, such as the anesthesia services or facility charges.

Note: the following applies to the charts on pages 70, 71 & 72.

  • PPO and Low Option Plan, in-network provider only.
  • Any additional recommendations provided in the future will be covered as of the first plan year beginning on or after the first anniversary of when the recommendations are updated.
  • Wellness Benefits are not available under the Low Option Plan.
  • Refer to recommendation listed in the July 2011 IOM report entitled "Clinical Preventive Services for Women": Closing the Gaps concerning individual preventive services that may be obtained during a well-women preventive service visit.

List of Covered Preventive Care Services: Network Only
Health Screenings For Adults
  • Blood pressure screening for adults
  • Cholesterol screening for men age 35 and older, women age 45 and older, and younger adults at higher risk
  • Diabetes screening for type 2 diabetes for adults with high blood pressure
  • HIV and sexually transmitted infections (STI) screenings for adults at higher risk
Cancer Screenings
  • Breast cancer mammography every 1 to 2 years for women over age 40
  • Breast cancer chemoprevention counseling for women at high risk for breast cancer
  • Cervical cancer pap test for women
  • Colorectal cancer screening including fecal occult blood testing, sigmoidoscopy or colonoscopy from age 50 to 75
  • Prostate cancer (PSA) screening for men
Health Counseling
  • Healthy diet
  • Weight loss
  • Tobacco use
  • Alcohol misuse
  • Depression
  • Prevention of STIs
  • Use of aspirin to prevent cardiovascular disease


  • Depression screening
  • Alcohol and drug use assessment
  • Cervical dysplasia screening for sexually active young women
  • Counseling to prevent sexually transmitted infections (STIs) for sexually active adolescents
  • HIV screening for adolescents at higher risk
for Men
  • Abdominal aortic aneurysm one-time screening for men age 65 to 75 who have smoked
for Women
  • Osteoporosis screening for women age 60 and older, depending on risk factors
  • BRCA counseling about genetic testing for women at higher risk
Specifically for Pregnant Women
  • Folic acid supplements for women who may become pregnant
  • Alcohol and drug use assessment
  • Tobacco cessation counseling for all pregnant women who smoke
  • Syphilis screening for all pregnant women
  • Hepatitis B screening during the first prenatal visit
  • RH incompatibility blood type at first prenatal visit and 24-28 weeks
  • Bacteriuria urinary tract infection screening at 12 to 16 weeks
  • Breastfeeding education to promote breastfeeding

List of Covered Preventive Care Services: Network Only
Children and Adolescents
Newborns Screening all newborns for:
  • Hepatitis A & B
  • Hypothyroidism
  • Phenylketonuria (PKU)
  • Sickle cell disease
  • Gonorrhea preventive medication for eyes of
    all newborns

Childhood /

  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type B
  • Hepatitis A & B
  • Human Papillomavirus (HPV)
  • Influenza (Flu)
  • Meningococcal
  • Pneumococcal
  • Inactivated Poliovirus
  • Rotavirus
  • Varicella (chickenpox)
  • Medical history of all children throughout development
  • Height, weight and Body Mass Index (BMI) measurements
  • Developmental screening for children throughout childhood
  • Autism screening for children at 18 and 24 months
  • Behavioral assessment for children of all ages
  • Vision screening
  • Oral health risk assessment for young children
  • Hematocrit or Hemoglobin screening
  • Obesity screening and weight-management counseling for children age 6 or older
  • Iron supplements for children 6 to 12 months who are higher risk for anemia
  • Floride supplements for children without fluoride in their water
  • Lead screening for children at risk of exposure
  • Dyslipidemia screening for children at higher risk of lipid disorder
  • Tuberculin testing for children at higher risk of tuberculosis
Additional Screenings for Adolescents
  • Depression screening
  • Alcohol and drug use assessment
  • Cervical dysplasia screening for sexually active young women
  • Counseling to prevent sexually transmitted infections (STIs) for sexually active adolescents
  • HIV screening for adolescents at higher risk

Type of Preventive Service HHS Guideline For Health
Insurance Coverage
Well-Women Visits Well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care. This well-woman visit should, where appropriate, include other preventive services covered by the Fund with no cost-sharing. Annual, as well as additional visits needed to obtain recommended preventive services as determined by the health care provider, depending on a woman's health status, health needs, and other risk factors.* (see note)
Screening for gestational diabetes Screening for gestational diabetes In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.
Human papillomavirus testing High-risk human papillomavirus DNA testing in women with normal cytology results. Beginning at age 30 and no more frequently than every 3 years, regardless of Pap smear results.
Counseling for sexually transmitted infections Counseling on sexually transmitted infections for all sexually active women. Annual
Counseling and screening for human immune deficiency virus Counseling and screening for human immune-deficiency virus infection for all sexually active women. Annual
Contraceptive methods and counseling All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity. As prescribed
Breastfeeding support, supplies, and counseling Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment. In conjunction with each birth
Screening and counseling for interpersonal and domestic violence Screening and counseling for interpersonal and domestic violence. Annual

Note: In accordance with the applicable requirements under PPACA, effective January 1, 2014, the Fund will not have any preexisting condition exclusions.

Reconstructive Mastectomy Benefit

In accordance with the requirements of the Women's Health and Cancer Rights Act of 1998, if the Fund provides medical and surgical benefits in connection with a mastectomy, the Fund will also provide benefits for certain reconstructive surgery. In particular, the Fund will provide, to a participant or beneficiary receiving or claiming benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for the following:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and/or
  • Prostheses and physical complications associated with all stages of mastectomy, including lymphedemas, in a manner determined in consultation between the attending physician and the patient.

To the extent permitted by applicable law, this coverage is subject to applicable copays, referral requirements, annual deductibles and coinsurance provisions that may apply under the Health Plan. If you have any questions, please contact the Administrative Office.

Skilled Nursing Facilities - (Preauthorization Required)*

Case Management may authorize coverage for a skilled nursing facility if it will benefit the patient and satisfy the Fund's medically necessaryMedical treatment that satisfies the definition of "necessary treatment." guidelines. The skilled nursing facility must also satisfy each of the following requirements:

  • The illness requires constant or frequent skilled nursing care on a 24-hour basis and/or while the patient is receiving rehabilitative services (at least five days per week), and this care cannot be safely or efficiently provided on an outpatient basis; and
  • There's an expectation that the patient will improve within a reasonable period of time that would permit him/her to be discharged home with minimal patient services.

* Please have your provider contact the Fund's Utilization Administrator to facilitate your care through Case Management Intervention.
On the backside of your medical ID card, you will find the phone number for Preauthorization or Pre-Service Review.

Speech Therapy

Speech therapy services, up to 100 visits annually, are eligible for coverage when prescribed by a physician to treat any of the following conditions:

  • An organic, objectively documented illness, an injuryBodily harm caused by an accident. The injury must also result, for the purposes of accidental death and dismemberment coverage, directly and independently of all other causes, in a loss covered by the plan. or surgery that affects the oral-motor mechanism;
  • Articulation disorder when diagnosed by a licensed speech pathologist;
  • Attention deficit hyperactivity disorder (ADHD), pervasive development disorder (PDD) or autism;
  • Cognitive disorders impairing speech as a result of an organic, objectively documented illness, an injury or surgery;
  • Congenital anomalies that have been surgically corrected;
  • Documented hearing loss for children who have failed to develop normal speech, based upon developmental norms for age;
  • Speech impairment by surgery, accidental injury, stroke, radiation injury, or other structural or neurological diseases; and/or
  • Speech impairment in a child who has failed to acquire comprehensible speech articulation as the result of hearing loss, Down's syndrome, cerebral palsy or another neurological disease.

Speech therapy is not an available benefit when it's part of an educational program for a child with learning delay unless the child has been diagnosed with of autism, pervasive developmental disorder, severe attention deficit hyperactivity disorder or another condition listed as eligible for speech therapy benefits in this section.

Only licensed speech therapists/pathologists are eligible providers of speech therapy.

Speech therapy benefits for your child must be coordinated with speech therapy benefits provided through your child's school. If your physician prescribes more than one speech therapy visit per week, you must provide satisfactory evidence to the Administrative Office that you have applied for the Federally mandated individual education program (IEP) benefit through your child's school. For each IEP-covered visit, the visits covered by the Fund will be reduced by one. When the IEP benefits are coordinated, the Fund pays for less than 100 visits each calendar year. If the IEP denies a request for speech therapy, you must provide documentation of the denial before the Fund will consider benefits. As with all Fund benefits, eligibility for benefits is subject to review for medical necessity.

Temporomandibular Joint Dysfunction (TMJ)

X-rays and physiotherapy visits per person at the applicable in-network or out-of-network benefit levels are covered. Charges for a TMJ appliance or splint, including follow-up visits for adjustments, will also be paid at applicable in-network or out-of network benefit levels.

Wellness Benefit

The PPO Plan provides each family with a calendar-year Wellness Benefit, up to a maximum calendar year limitation.  (See the Summary of Benefits, page 12 for the maximum amount):

  • Routine physical examinations;
  • Well child care for children age seven and older;
  • Flu shots, vaccinations and immunizations. Charges in connection with a wellness visit for children under age seven are considered an eligible expense under the plan's benefits rather than under the wellness benefit;
  • Smoking cessation programs;
  • Weight-loss programs if the program includes treatment for a specific disease diagnosed by a physician. Programs that require attendance, such as Weight Watchers, will be reimbursed only after services are rendered. Proof of attendance is required when you submit your claim;
  • Nutritional counseling if to treat a specific disease diagnosed by a physician;
  • Genetic testing;
  • Lifestyle classes and Fitness Enhancement (offered at the Motion Picture & Television Fund Health Centers (MPTF) located in Southern California);
  • Routine Mammograms; and
  • Routine Pap Smears.

*The Fund will cover certain preventive services at 100% with no deductible or co-payment if they are rendered by an in-network provider. Please see page 69 for more details about these services.

As with all Fund benefits, only services performed by a licensed practitioner will be covered by the wellness benefit. If you want to know if a service or treatment is covered under the wellness benefit before you go to a provider, contact the Administrative Office.

Note: If the wellness benefit is exhausted, the expenses will be considered under medical benefits, subject to the Plan's annual deductible and out-of-pocket maximum. This rule doesn't apply to the Low Option Plan. See the Summary of Benefits for more information.


Wigs are covered, if necessary due to injury, disease or treatment of an injury or disease, but not for cosmetic reasons.

Expenses Not Covered

Notwithstanding the above, none of the medical plans cover any of the following expenses:

  1. Acupressure or massage therapy.
  2. Acupuncture (except for treatment of chronic pain).
  3. Air conditioners, humidifiers, allergy-free pillows, mattress covers and similar environmental control equipment.
  4. Autologous blood storage charges, unless in association with a scheduled surgery that is normally covered by the Fund.
  5. Bariatric surgery, unless it meets the Plan's requirement for bariatric surgery (available in writing from the Fund office).
  6. Charges associated with the translation of foreign claims.
  7. Charges billed for procedure codes determined by the Plan to be incidental or mutually exclusive to or unbundled from a more global procedure code, except as determined by network pricing.
  8. Charges for completing claim forms, reports, etc.
  9. Charges for copying medical file records, except when requested by the Fund for medically necessary review.
  10. Charges for eye refraction, eye exams, contact lenses and eyeglasses, except as provided under the vision plan. (See "What's Covered" on page 61 for details). Any surgical procedure, such as LASIK, to correct a refractive error.
  11. Charges for mailing and shipping of medical supplies.
  12. Charges for umbilical cord blood collection, to randomly freeze and/or store umbilical cord blood for possible future use.
  13. Charges in connection with private duty or full-time nursing care while hospitalized.
  14. Charges in connection with the pregnancy of dependent children, except as described under the "Preventive Care Benefits" on page 70. However, complications of pregnancy Conditions requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy. Examples are acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity.

    The following are not considered complications of pregnancy: false labor; occasional spotting; physician-prescribed rest during pregnancy; morning sickness; hyperemesis gravidarum; pre-eclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; an elective Caesarean section; an ectopic pregnancy that is terminated; or a spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible.

    Complications of pregnancy as defined above are covered under the plan to the same extent as any other sickness.
    are covered.
  15. Charges the patient is not required to pay.
  16. Christian Science treatment.
  17. Cold or heat therapy equipment for home use.
  18. Collagen or fat injections.
  19. Collection, processing and storage of self-donated blood, unless it is specifically collected for a planned and covered surgical procedure.
  20. Concierge medical supplies or other personalized medicine services billed by an unlicensed provider and as an all-inclusive package.
  21. Cosmetic surgeryProcedures performed primarily to make an improvement in a person's appearance. Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance or self-esteem. Reconstructive surgery, unlike cosmetic surgery, is covered. Reconstructive surgery is performed on abnormal structures of the body, resulting from congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Reconstructive surgery is generally performed to improve function, but may also be done to approximate a normal appearance. or related complications, except life-threatening complications, and prescription drugs prescribed for cosmetic purposes.
  22. Cultured chondrocyte transplantation to joints other than the knee.
  23. Custodial Care in convalescent homes, nursing or rest homes, or institutions of a similar nature.
  24. Custodial Care or Rest CuresCare designed to help a person in the activities of daily living. Continuous attention by trained medical or paramedical personnel is not necessary. Such care may involve:
    • Preparation of special diets;
    • Supervision of medication that can be self-administered; and
    • Helping the person get in or out of bed, walk, bathe, dress, eat or use the toilet.
    , as defined on page 126, whether received at home, in a Skilled Nursing Facility or in a hospital.
  25. Custodial Shift Care is not covered.
  26. Cutting, trimming, or partial removal of toenails, corns and calluses, except when medically necessary due to vascular impairment or loss of protective sensation caused by diabetes or other disease.
  27. Dental expenses, including bone or metal bases for dental implants, except:
    • Treatment rendered within 90 days of accidental injuries to sound natural teeth (due to external blow), including the replacement of such teeth. (There is no guarantee that treatment will be covered. The expense must be reviewed and be deemed medically necessary); or
    • Setting of jaw fractured or dislocated in an accident. Dental expenses may be covered under the Dental Plan. (See Section 4: Dental Benefits for details).
  28. Diet pills or homeopathic remedies.
  29. Education training, equipment or supplies, except those mandated by law.
  30. Educational therapy, academic evaluations, play therapy, or treatment of learning disabilities.
  31. Erectile dysfunction prescription drugs.
  32. Expenses incurred that are not due to illness or injury.
  33. Expenses that are in excess of R&C charges as defined in the Glossary.
  34. Expenses that are not approved by a physician.
  35. Expenses that are not considered necessary treatment as defined in the Glossary.
  36. Expenses written off by the provider or not charged to the patient.
  37. Experimental or investigational treatments (See the Glossary for the definition of "Investigational/Experimental Treatment").
  38. Extra or increased charges, in addition to basic services, for services provided after hours, or during late hours at a 24-hour facility, or on weekends and holidays, or on an emergency basis.
  39. Fees charged by masseurs, masseuses, dance therapists, or for Pilates or yoga, even when prescribed by a physician.
  40. Fees for a surgical suite unless the facility is state licensed and/or Medicare approved as an ambulatory surgical facility, or has certification from a private accreditation agency accepted by the state in lieu of state licensure.
  41. Fees for membership at a health club, gymnasium, YMCA or similar facility.
  42. Food supplements, except those that require a prescription or that are essential to the treatment of special metabolic conditions and approved as medically necessary.
  43. Home infusion therapy, unless authorized through case management intervention as described here.
  44. Home uterine monitoring, except as approved as medically necessary.
  45. Hospital confinement or service which is not approved by a physician.
  46. Hospitalization primarily for diagnostic studies.
  47. Hydrocolators, whirlpool baths, sunlamps, heating pads and exercise devices, except as provided under "Inversion Device", and similar general-use items.
  48. Hydrotherapy if used for exercise purposes.
  49. Hypnosis.
  50. Illness or injury caused by declared or undeclared war or act of war.
  51. Illness or injury sustained during the commission of a felony.
  52. Incontinence supplies, except when approved as medically necessary.
  53. Infertility treatments, including but not limited to ovulation stimulation, insemination, in vitro fertilization with embryo transfer, gamete intrafallopian transfer and zygote intrafallopian transfer.
  54. Intentionally self-inflicted injury, suicide or attempted suicide, except when the product of a mental disorder.
  55. Internet or email consultations or testing.
  56. Loss caused by illness or injury:
    • That arises out of, or occurs in the course of, any occupation or employment for wage or profit; or
    • For which the covered person is entitled to any benefits under a Workers' Compensation or occupational disease law.
  57. Medication or devices used for contraception, except when covered under the rules regarding those contraceptives that are described under "Prescription Drug Benefits" on page 55 or under "Preventive Care Benefits" on page 69.
  58. Medical care received in a United States or Canadian government-operated hospital or from physicians employed by those governments, except charitable research hospitals, unless mandated by law.
  59. Medical expenses incurred by an organ donor for an eligible participant or dependent to the extent that such expenses are eligible for coverage under the donor's own group health insurance.
  60. Neuromuscular stimulator or similar equipment, except when appropriate to prevent or treat muscular atrophy due to neuromuscular disease or injury (not covered to prevent or treat disuse atrophy due to pain, including post-operative pain) and should be used for pain management.
  61. Outpatient prescription drugs and medicines not billed as part of a facility charge, except those prescribed through case management intervention as part of home health care. (Outpatient prescription drug benefits are described under "Prescription Drug Benefits").
  62. Outpatient vitamins except for B12 injections when medically necessary for pernicious anemia or other B12 deficiency, food supplements and over-the-counter drugs.
  63. Over-the-counter supplies for home care, such as bandages, cotton swabs, cotton balls, alcohol pads, gauze pads or similar products.
  64. Parallel bars, biofeedback equipment or similar institutional equipment that is appropriate for use in a medical facility and is not appropriate for use in the home.
  65. Patient or provider travel costs or expenses.
  66. Personal comfort or convenience items, including diapers and modifications to a home to facilitate care, such as a raised toilet seat or a shower bench.
  67. Prepared child birth classes (including Lamaze), parenting classes and doulas.
  68. Reversal of vasectomies or tubal ligation.
  69. Replacement batteries for Durable Medical Equipment.
  70. Routine foot care including heel lifts, and shoe inserts except when special shoes/inserts are necessary to prevent complications of diabetes. Orthopedic shoes are subject to medically necessary review.
  71. Routine physical examinations, preventive treatment or well child care, including tests, for children age seven or older, except as described under "Wellness Plan".
  72. Sales or other taxes on services, products and equipment.
  73. Services and supplies for which the patient is not legally required to pay.
  74. Services incidental to outpatient tests, procedures, or examination, including venipuncture, specimen handling and conveyance, unless allowed by network pricing or clinical editing system.
  75. Services received from a health care provider who is a member of your immediate family, or living with the person requiring treatment;
  76. Supports or devices used primarily for safety or performance in sports-related activities.
  77. Transportation, except local ambulance services for emergency services.
  78. Unlicensed assistive personnel and/or providers whose services are custodial in nature, including but not limited to home health aides.

From time to time, other non-covered expenses may be added to this partial list. If you're not sure whether a particular treatment or service is covered, contact the Administrative Office. (For contact information, see the Summary Of Benefits, page 16.)