Ambulance transport – appropriately licensed ambulance services to or from the nearest hospital that can provide medical care and treatment when medically necessary. This includes air ambulance when medically necessary. The claims administrator determines if the air ambulance service qualifies as medically necessary.

Cardiac and pulmonary rehabilitation (Phases I and II) – includes inpatient and outpatient treatment. Phase I rehabilitation is covered in conjunction with an inpatient confinement. Phase II rehabilitation is covered on an ambulatory basis and is limited to 90 days per calendar year (combined with outpatient short-term rehabilitation services).

Chiropractic therapy – limited to $1,500 per calendar year for medically necessary treatment of injury or illness.

Contact lenses and eyeglasses – limited to the first pair following cataract surgery, for the initial replacement of natural lenses. The Medical Program does not pay benefits for the purchase of contacts or eyeglasses, unless they are necessary to treat an illness or injury.

Dental care – limited to the treatment of a fractured jaw or the repair of an accidental injury to sound, natural teeth that is sustained while covered under the Medical Program. Treatment must begin within six months following the accident or injury. Appliances necessary to stabilize the joint and for necessary surgery for treatment of temporomandibular joint (TMJ) dysfunction syndrome are covered. Hospital facility charges and anesthesia may be covered subject to medical necessity. Services for orthognathic surgery may be covered subject to medical necessity.

Durable medical equipment – equipment that is provided for use in the home, including (but not limited to) external insulin pumps, oxygen, and ostomy supplies. This also includes equipment rental charges such as wheelchairs, hospital beds, and any device that provides mechanical ventilatory support.

External prosthetic appliances – any appliance that is provided to replace or substitute a missing body part and that is necessary to alleviate or correct sickness, injury, or a congenital defect. This includes the initial fitting and purchase of an external prosthetic device, including:

Artificial lenses;

Artificial limbs;

Terminal devices (such as a hand or hook); and

External breast prostheses.

The Program pays benefits for the replacement only if it is needed due to normal body growth. The Program does not pay benefits for charges related to wear and tear.

Home health care – includes short-term rehabilitative home health care services that are ordered by a physician and provided by an appropriately licensed home health care agency. Care must be provided in conjunction with an approved treatment program. Covered charges include:

Part-time or intermittent nursing care provided by or under the supervision of a registered graduate nurse or home health aide (the claims administrator must approve private-duty nursing care).

Physical, occupational, and speech therapies.

Consumable medical supplies, drugs, and medicines lawfully dispensed only on the written prescription of a physician, including (but not limited to):

Oxygen;

Ostomy supplies;

Consumable medical supplies as part of authorized inpatient or outpatient facility services;

Consumable medical supplies as part of home care when used directly by an authorized, skilled professional; or

Authorized consumable medical supplies used in conjunction with authorized durable medical equipment as determined by the claims administrator.

Laboratory services, but only to the extent that the charges would have been considered covered expenses if the covered individual had required confinement in the hospital as a registered bed patient or confinement in a skilled nursing facility.

Dietary supplements and nutritional formula for PKU or other protein absorption deficiencies. The Medical Program also covers nutritional supplements for life-sustaining nutrition that you or your spouse/domestic partner may receive via a gastrointestinal tube or intravenously in a home setting if you or your spouse/domestic partner is no longer capable of swallowing.

Home health visit – services provided by a registered professional employed by a certified home health care agency in conjunction with a written treatment program. A two-hour visit provided by a home health aide employed by a certified home health agency may be substituted for one visit.

Hospice – services provided in an inpatient facility or outpatient setting if you or your covered spouse/domestic partner is diagnosed as having an incurable disease with a life expectancy of six months or less. Covered charges, if determined to be medically necessary by the claims administrator, include:

Precertified hospice facility room and board for a semiprivate room (private room charges are covered up to the cost of the facility’s highest daily rate for a semiprivate room at the time of the covered individual’s confinement);

Hospice facility services and supplies during the precertified confinement;

Outpatient services provided by a hospice facility;

Professional services of a licensed physician;

Pain relief treatment, including drugs, medicines, and medical supplies;

Part-time or intermittent nursing care provided in the home by or under a nurse’s supervision;

Part-time or intermittent services provided in the home by a home health aide;

Consumable medical supplies, drugs, and medicines that are lawfully dispensed only on the physician’s written prescription, and laboratory services (only to the extent that such charges would have been payable if the person had remained or been confined in a hospital or hospice facility); and

Other covered charges or services that are determined to be medically necessary and are authorized by the claims administrator.

Inpatient skilled nursing and rehabilitation – requires precertification if you or your spouse/domestic partner is under age 65, but no prior hospitalization is required. Covered charges include:

Regular daily services and supplies provided by the skilled nursing facility (including routine nursing care, prescription drugs, and physical and speech therapy), and covered at the specified percentage of covered charges; and

Private-duty professional nursing services provided by a registered graduate nurse or an appropriately licensed practical nurse (other than a close relative of the covered individual). The services must be provided in conjunction with an approved stay in a skilled nursing or rehabilitation facility.

Orthopedic shoes and orthotic appliances – charges related to foot care treatment, if medically necessary, for orthotics or corrective shoes.

Outpatient short-term rehabilitation therapies – includes short-term physical, speech, and occupational therapy of a restorative nature to treat an injury or illness. Such services must be provided by an appropriately licensed physical, occupational, or speech therapist. Speech loss or impairment due to a mental or nervous disorder is not covered. Outpatient short-term rehabilitation therapy is limited to a maximum of 90 days per calendar year (combined with cardiac and pulmonary rehabilitation therapy). No prior hospitalization is required.

Reconstructive surgery – charges for surgery required when an individual sustains an illness or injury that results in bodily damage that requires restoration of a prior functional status, provided it:

Qualifies as reconstructive surgery following medically necessary surgery for the specific illness or injury; or

Is required to provide or restore a normal bodily function.

Surgical support hose and Jobst® stockings – limited to three pairs per calendar year, when determined medically necessary and authorized by the claims administrator.