Eligible Expenses From A To Z
The Regular 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 deductible, the Fund will pay a percentage of charges for medically necessary expenses required to treat an illness or injury. (Click here for the definition of "medically necessary.") 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.)

The following eligible expenses 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 R&C amount.

Alternative Medical Benefit
Benefits for therapy when referred by a medical physician and provided by a "covered provider" are covered for any combination of the following services and therapies:

• Acupuncture for pain control;
• Biofeedback therapy;
• Chiropractic care;
• Lymphedema therapy;
• Naturopathy;
• Occupational therapy;
• Osteopathic manipulative therapy; and
• Physical therapy.

All services listed above accumulate under the Alternative Medical Benefit as described in the Summary Of Benefits. Your per-session reimbursement level varies by plan. Refer to the Summary Of Benefits or call the Administrative Office for your plan's benefit details.

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

Elective Surgery - Network Second Opinion
The services of 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&C charges over and above what it would otherwise pay.

Electro Convulsive Therapy (ECT)
Physician-prescribed ECT is covered.

Enhanced External Counterpulsation (EECP) Therapy
EECP therapy is covered. (See the Summary Of Benefits for details.)

Home Health Care (Available Only Through Case Management Intervention)
Home health care services are provided to individuals who are considered to be home-bound. These services are covered when they're ordered by your physician and reviewed by your case manager. 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:

• Used in place of hospital or skilled nursing facility confinement or otherwise meet case management requirements; and
• Periodically reviewed for medical necessity through case management. Custodial care (such as bathing, dressing or cooking) is not a covered benefit.

Home Infusion Therapy (Available Only Through Case Management Intervention)
Home infusion care (i.e., the administration of medication in the home setting as an alternative to hospitalization) is covered when your physician and your case manager have determined it's 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 (Available Only Through Case Management Intervention)
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. Hospice programs enable terminally ill patients to remain in the familiar surroundings of their home for as long as they can. 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;
• Pain management and symptom control;
• Instruction and supervision of caregivers;
• 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 case manager 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 management.

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. Coverage is limited to one device per ear every three years;
• 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 case management and subject to limitations (see the Summary Of Benefits 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's 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 unit 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 equipment (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;
• 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 because it's a treatment for chronic back problems. Documentation of at least six months of prior medical treatment is required.

Mastectomy Benefit
Under federal law, you and your covered dependents have the right as participants in a group health plan to receive coverage for the following services in connection with a mastectomy:

• Reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment for physical complications for all stages of a mastectomy, including lymphedemas (i.e., swelling associated with the removal of lymph nodes).

Mental Health And Substance Abuse
Hospital and professional services for inpatient and outpatient treatment of mental health disorders, including substance abuse, are covered. If you are covered under the Regular or Low Option Plan, you may receive care from PBH or non-PBH providers, as described here.

Organ And Tissue Transplants

Organ and tissue transplants must be preauthorized to be eligible for coverage. If authorization isn't received, coverage will be denied.

The following organ and tissue transplants are eligible for coverage:

• Bone marrow transplants, either autologous or allogeneic;
• Bone transplants;
• Corneal transplants;
• Heart-lung transplants;
• Heart transplants;
• Kidney-pancreas transplants;
• Knee chondrocyte transplants;
• Liver transplants;
• Lung transplants;
• Renal transplants; and
• Stem cell transplants.

Each transplant case will be reviewed by the Fund. 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 case management 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 here. 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.

Skilled Nursing Facilities - Available Only Through Case Management Intervention
Case management may authorize coverage for a skilled nursing facility if it will benefit the patient and satisfy the Fund's medically necessary 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.

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 injury 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
• 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 in the absence 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 Disfunction (TMJ)
X-rays and a specific lifetime total of physiotherapy visits per person at the applicable network or non-network benefit levels are covered. Charges for an appliance or splint, including follow-up visits for adjustments, also will be paid at applicable network or non-network benefit levels, up to a specific lifetime maximum benefit.

Wellness Benefit
The Regular Plan provides each family with a calendar-year preventive care benefit, up to a maximum dollar amount, for:

• 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; and
• Genetic testing.

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.

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

Expenses Not Covered From A To Z
None of the medical plans cover any of the following expenses:

• Acupressure or massage therapy;
• Acupuncture (except for treatment of chronic pain);
• Care in convalescent homes, nursing or rest homes, or institutions of a similar nature;
• Charges for eye refraction, eye exams, contact lenses and eyeglasses, except as provided under the vision plan. (See "What's Covered");
• Charges in connection with private duty or full-time nursing care while hospitalized;
• Charges in connection with the pregnancy of dependent children. However, complications of pregnancy are covered;
• Charges the insured patient isn't required to pay;
• Charges to randomly freeze and/or store umbilical cord blood for possible future use;
• Christian Science treatment;
• Collagen or fat injections;
• Collection, processing and storage of self-donated blood, unless it is specifically collected for a planned and covered surgical procedure;
• Cosmetic surgery or related complications, except life-threatening complications, and prescription drugs prescribed for cosmetic purposes;
• Cultured chondrocyte transplantation to joints other than the knee;
• Custodial care, as defined on page 99, whether received at home, in a skilled nursing facility or in a hospital. Custodial shift care is not covered;
• 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 3: Dental Benefits for details);
    
    
• Diet pills or homeopathic remedies;
• Education training, equipment or supplies, except those mandated by law;
• Educational therapy and academic evaluations;
• Erectile dysfunction prescription drugs;
• Expenses incurred that are not due to illness or injury;
• Expenses that are in excess of R&C charges as defined in the Glossary;
• Expenses that are not approved by a physician;
• Expenses that are not considered necessary treatment as defined in the Glossary;
• Experimental or investigational treatments (See the Glossary for the definition of "investigational/experimental or treatment");
• Fees charged by masseurs, masseuses, dance therapists, or for Pilates or yoga, even when prescribed by a physician;
• Fees for membership at a health club, gymnasium, YMCA or similar facility;
• Food supplements, except those that require a prescription or that are essential to the treatment of special metabolic conditions. These will be reviewed by case management;
• Growth hormone treatment for children with normal growth hormone levels but who are short in stature;
• Home IV infusion therapy, unless authorized through case management intervention as described on here;
• Home uterine monitoring, except as approved through case management;
• Hydrocolators, whirlpool baths, sunlamps, heating pads and exercise devices, except as provided under "Inversion Device" , and similar general-use items;
• Hydrotherapy if used for exercise purposes;
• Hypnosis;
• Illness or injury caused by declared or undeclared war or act of war;
• Illness or injury sustained during the commission of a felony;
• Infertility treatments, including but not limited to ovulation stimulation, insemination, in vitro fertilization with embryo transfer, gamete intrafallopian transfer and zygote intrafallopian transfer;
• Intentionally self-inflicted injury, suicide or attempted suicide, except when the product of a mental disorder;
• 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;
• 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;
• Medication or devices used for contraception, except when covered under the rules regarding oral contraceptives, which are described under "Prescription Drug Benefits";
• Orthoptic treatments (i.e., eye training or visual programs), except for children under age seven or due to trauma;
• 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");
• 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;
• Routine physical examinations, preventive treatment or well child care, including tests, for children age seven or older, except as described under "Wellness Benefit";
• Services received from a health care provider who is a member of your immediate family, or living with the person requiring treatment;
• Substance abuse treatment, except as described under "Mental Health and Substance Abuse Benefits";
• Surgical procedures or treatments to alter a person's sex or reversals thereof;
• Surgical procedures to correct visual acuity;
• Surgical suites, unless the facility qualifies as an ambulatory surgical center with the appropriate state license and accreditations;
• Transportation, except emergency ambulance service as described under "Hospitals, Surgical, Medical";
• Treatment of seborrheic keratosis, unless inflamed or determined by a dermatologist to require a pathology evaluation for malignancy, and vitiligo;
• Vitamins, except those requiring a prescription; and
• Weight control or weight loss programs, unless for the treatment of morbid obesity, diabetes, hypertension or hyperlipidemia or as part of the wellness benefit.

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 Claims Administrator. (For contact information, see the Summary Of Benefits.)