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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace   
How the Retiree Group Health Program Works
What Is an Expense That May Be a Covered Expense – Medical Program
Professional Services
Allergy treatment – services provided in a physician’s office for the diagnosis and treatment of allergies.
Bariatric surgery – covered on an in-network basis only. You or your spouse/domestic partner must meet claims administrator-specific criteria for the in-network surgery to be approved and covered by the Medical Program. These criteria generally include, but are not limited to, a minimum BMI, physician approval, unsuccessful attempts at weight loss via a physician-supervised established weight loss program(s), and other health side effects. Please work with the claims administrator to confirm the preapproval process and criteria surrounding coverage of bariatric surgery.
Hearing exams – services provided to determine hearing status. Hearing exams and aids are covered when due to an injury or illness, up to $1,000 per 36-month period.
Inpatient hospital professional services – services that are provided by an appropriately licensed physician during an inpatient confinement and in conjunction with an inpatient admission.
Multiple surgeries – surgical procedures during one operating session that are secondary or incidental to the primary surgery. The maximum amount that the Medical Program pays is the amount otherwise payable for the most expensive procedure, and half of the amount otherwise payable for all other procedures. The Medical Program pays benefits for any charge that is made by an assistant or co-surgeon, up to 20% of the primary surgeon’s allowable charge. (For purposes of this covered expense, “allowable charge” means the covered amount payable to the surgeon prior to any reductions due to coinsurance or deductible amounts.)
Outpatient professional services – services that are provided by an appropriately licensed physician in conjunction with outpatient services that are provided at a hospital or a licensed outpatient surgical facility. Such services may include those services provided by a pathologist, radiologist, anesthesiologist, emergency medicine physician, oncologist, or nephrologist, and includes inpatient facility and outpatient setting.
Physician office visits – services that are provided in a physician’s office, including routine preventive care and the diagnosis and treatment of an illness and injury. Such services may also include emergency care services. Lab/X-rays that are sent to and billed by an independent lab/X-ray facility will be paid under the independent lab/X-ray facility benefit.
Preventive care – services include well-woman exams, annual routine physicals to detect illness, and early cancer detection screenings. The components that make up a preventive care examination are determined by your age, gender, and health status.
Under the CIGNA Open Access Plus option, the Medical Program pays benefits for preventive care only if you or your spouse/domestic partner goes to a participating provider. In addition, gynecological exams are covered only if you or your spouse/domestic partner receives care from a participating OB/GYN. If you or your spouse/domestic partner receives preventive care services from a provider or at a hospital that is outside the network, the Medical Program does not pay benefits.
Women’s breast health services – such services include all medically necessary, non-experimental surgery and supplies. In addition, the Medical Program also pays benefits for certain breast reconstruction services in connection with a mastectomy. This coverage includes:
 | Reconstruction of the breast on which the mastectomy was performed;
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| Surgery and reconstruction of the other breast to produce a symmetrical appearance;
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| Prosthesis and physical complications for all stages of the mastectomy, including lymphedema; and
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| Charges for brassieres purchased incidental to mastectomy or reconstructive breast surgery. |
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