2009 Brochure - Section 5a

Section 5(a). Medical services and supplies provided by physicians and other health care professionals

What's in this Section:
� Diagnostic and treatment services � Lab, X-ray, and other diagnostic tests � Preventive care, adult � Preventive care, children � Maternity care � Family planning � Infertility services � Allergy care � Treatment therapies � Physical and occupational therapy	� Speech therapy � Hearing services (testing, treatment, and supplies) � Vision services (testing, treatment, and supplies) � Foot care � Orthopedic and prosthetic devices � Durable medical equipment (DME) � Home health services � Chiropractic � Alternative treatments � Educational classes and programs

Important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
The calendar year deductible is: $250 per person ($500 per family) under the High Option and $300 per person ($600 per family) under the Standard Option. The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

Benefit Description	You Pay After the calendar year deductible...
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.
Diagnostic and treatment services	High Option	Standard Option
Professional services of physicians Office visits and consultations, including second surgical opinion Note: We cover one routine physical exam and one routine gynecologic exam for women age 18 and older, per calendar year.	PPO: $20 copayment per office visit (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: $20 copayment per office visit (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Same day services performed and billed by the doctor in conjunction with the office visit	PPO: 10% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Professional services of physicians In an urgent care center During a hospital stay In a skilled nursing facility Examination during a hospital stay of a newborn child covered under a family enrollment Emergency room physician care	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Lab, X-ray and other diagnostic tests
Tests, such as: Blood tests Urinalysis Non-routine pap tests Pathology X-rays Non-routine Mammograms CAT Scans/MRI Ultrasound Electrocardiogram and EEG Note: We cover lab, X-ray and other diagnostic tests (also see Preventive care, adult) related to one routine physical exam and one routine gynecologic exam for women age 18 and older, per calendar year. Non-routine or more extensive tests as determined by the Plan are not covered under this benefit.	PPO: 10% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount Note: If your PPO provider uses a non-PPO laboratory or radiologist, we will pay non-PPO benefits for any laboratory and X-ray charges.	PPO: 15% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount Note: If your PPO provider uses a non-PPO laboratory or radiologist, we will pay non-PPO benefits for any laboratory and X-ray charges.
Quest Lab Program -- You can use this voluntary program for covered lab services. Testing must be performed by Quest Diagnostics. Ask your doctor to use Quest for lab processing. To find a location near you, visit our Web site at www.SambaPlans.com	Nothing for services obtained through the Quest Lab Program (No deductible)	Nothing for services obtained through the Quest Lab Program (No deductible)
Preventive care, adult
Cancer screenings, including: Fecal occult blood test for members age 40 and older Routine Prostate Specific Antigen (PSA) test -- one annually for men age 40 and older Routine pap test	PPO: Nothing (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: Nothing (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Sigmoidoscopy, screening -- every five years starting at age 50 Colonoscopy -- every 10 years starting at age 50 Double contrast barium enema -- every five years starting at age 50	PPO: 10% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Routine screenings, limited to: Total blood cholesterol Chlamydial infection Osteoporosis screenings, once every two years, for women age 65 and older	PPO: 10% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Routine mammogram -- covered for women age 35 and older, as follows: From age 35 through 39, one during this five year period From age 40 and older, one every calendar year	PPO: Nothing (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: Nothing (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Adult routine immunizations endorsed by the Centers for Disease Control and Prevention (CDC):	PPO: Nothing (No deductible) Non-PPO: Any difference between our allowance and the billed amount (No deductible)	PPO: Nothing (No deductible) Non-PPO: Any difference between our allowance and the billed amount (No deductible)
Not covered: Routine immunizations not endorsed by the Centers for Disease Control and Prevention (CDC)	All charges	All charges
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics for dependent children to age 22	PPO: Nothing (No deductible) Non-PPO: Any difference between the Plan allowance and the billed charge (No deductible)	PPO: Nothing (No deductible) Non-PPO: Any difference between the Plan allowance and the billed charge (No deductible)
The office visit for routine well-child care examinations (to age 22) Same day services performed and billed by the doctor in conjunction with the office visit	PPO: Nothing (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: Nothing (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
� Laboratory tests, including blood lead level screenings Note: See Lab, X-ray and other diagnostic tests on page 23 for information regarding services obtained through the Quest Lab Program.	PPO: 10% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance (No deductible) Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Maternity care
Complete maternity (obstetrical) care, such as: Prenatal care Delivery Postnatal care Note: Here are some things to keep in mind: You do not need to precertify your normal delivery; see page 11 for other circumstances, such as extended stays for you or your baby. You may remain in the hospital up to 48 hours after admission for a regular delivery and 96 hours after admission for a cesarean delivery. We will cover an extended stay if medically necessary, but you, your representative, your doctor, or your hospital must precertify. We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. We pay hospitalization and surgeon services (delivery and newborn circumcision) the same as for illness and injury. See Hospital benefits (Section 5(c)) and Surgery benefits (Section 5(b)).	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Routine sonograms to determine fetal age, size or sex Stand-by doctor for cesarean section Services before enrollment in the Plan begins or after enrollment ends	All charges	All charges
Family planning
A range of voluntary family planning services, limited to: Voluntary sterilization (See Surgical procedures Section 5b) Surgically implanted contraceptives Injectable contraceptive drugs (such as Depo provera) Intrauterine devices (IUDs) Diaphragms Note: We cover oral contraceptives under the prescription drug benefit.	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Reversal of voluntary surgical sterilization Genetic counseling Genetic testing Expenses for sperm collection and storage	All charges	All charges
Infertility services
Diagnosis and treatment of infertility, except as shown in Not covered. Note: Benefits are limited to $5,000 per person, per lifetime under the High Option and $2,500 per person, per lifetime under the Standard Option.	PPO: 10% of the Plan allowance and all charges after the Plan has paid $5,000 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $5,000	PPO: 15% of the Plan allowance and all charges after the Plan has paid $2,500 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $2,500
Not covered: Infertility services after voluntary sterilization Any charges in excess of the $5,000 (High Option) and $2,500 (Standard Option) plan limitation for covered infertility services Fertility drugs Assisted reproductive technology (ART) procedures, such as: artificial insemination in vitro fertilization embryo transfer and gamete intrafallopian transfer (GIFT) intravaginal insemination (IVI) intracervical insemination (ICI) intrauterine insemination (IUI) Services and supplies related to ART procedures Cost of donor sperm or egg Expenses for sperm collection and storage Surrogacy (host uterus/gestational carrier)	All charges	All charges
Allergy care
Allergy injections, testing and treatment, including materials (such as allergy serum)	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Provocative food testing and sublingual allergy desensitization Clinical ecology and environmental medicine	All charges	All charges
Treatment therapies
Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 38 and 39. Dialysis - Renal dialysis, hemodialysis and peritoneal dialysis Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy Transparenteral nutrition (TPN) Medical foods and nutritional supplements when administered by catheter or nasogastric tubes Growth hormone therapy (GHT) Note: Growth hormone is covered under the prescription drug benefit. Note: We only cover GHT when we preauthorize the treatment. Call Medco Health at 1-800/753-2851 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Other services under How to get approval for... in Section 3. Respiratory and inhalation therapies Cardiac rehabilitation	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Physical and occupational therapies
Services of a qualified physical therapist, occupational therapist, doctor of osteopathy (D.O.), or physician for the following: Physical therapy Occupational therapy Benefits are limited to $3,000 per person per calendar year under High Option and $2,000 per person per calendar year under Standard Option.	PPO: 10% of the Plan allowance and all charges after the Plan has paid $3,000 Non-PPO: Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $3,000	PPO: 15% of the Plan allowance and all charges after the Plan has paid $2,000 Non-PPO: Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $2,000
Not covered: Long-term rehabilitative therapy Exercise programs	All charges	All charges
Speech therapy
Speech therapy Note: Covered expenses are limited to charges of a licensed speech therapist for speech loss or impairment due to (a) congenital anomaly or defect, whether or not surgically corrected or (b) due to any other illness or surgery.	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Hearing services (testing, treatment, and supplies)
Hearing screenings, testing, diagnostic evaluation, and treatment by a licensed hearing professional for adults. Note: Benefits for hearing aids are limited to $500 per person/adult, per lifetime.	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	All charges
Hearing screenings, testing, diagnostic evaluation, and treatment by a licensed hearing professional for dependent children up to the age of 22. Note: Benefits for hearing aids are limited to $1,000 per newborn/child, per lifetime.	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Hearing testing, except as stated above Hearing aids, testing and examinations for them, except as stated above Any charges in excess of the $1,000 per newborn/child, per lifetime Plan limitation for hearing aids Any charges in excess of the $500 per person/ adult, per lifetime Plan limitation for hearing aids Replacement batteries for hearing aids	All charges	All charges
Vision services (testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts) Vision therapy, such as eye exercises or orthoptics	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Eyeglasses or contact lenses and examinations for them except as noted above Refraction Radial keratotomy, lasik and other refractive surgery	All charges	All charges
Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. Removal of nail root Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.	PPO: $20 copayment for the office visit (No deductible) plus 10% of the Plan allowance for other services Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: $20 copayment for the office visit (No deductible) plus 15% of the Plan allowance for other services Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)	All charges	All charges
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose Orthopedic and corrective shoes Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy Lumbosacral supports Crutches, surgical dressings, splints, casts, and similar supplies Braces, corsets, trusses, elastic stockings, support hose, and other supportive devices Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See Section 5(b) for coverage of the surgery to insert the device. Note: We will pay only for the cost of the standard item. Coverage for specialty items such as bionics is limited to the cost of the standard item. Dental prosthetic appliances are covered under High Option Section 5(g).	PPO: 10% of the Plan allowance Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount
Not covered: Penile prosthetic Wigs Arch supports and foot orthotics Heel pads and heel cups	All charges	All charges
Durable medical equipment (DME)
Durable medical equipment (DME) is equipment and supplies that: Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury) Are medically necessary Are primarily and customarily used only for a medical purpose Are generally useful only to a person with an illness or injury Are designed for prolonged use; and Serve a specific therapeutic purpose in the treatment of an illness or injury We cover rental (up to the purchase price) or purchase, of durable medical equipment, at our option, including repair and adjustment. Covered items include: Oxygen equipment and oxygen; Hospital beds; Wheelchairs; and Walkers Benefits are limited to $25,000 per person, per lifetime under the Standard Option. Note: We will pay only for the cost of the standard item. Coverage for specialty equipment, such as all-terrain wheelchairs, is limited to the cost of the standard equipment.	PPO: 10% of the Plan allowance Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance and all charges after the Plan has paid $25,000 (lifetime) Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $25,000 (lifetime)
Not covered: Equipment replacements provided less than 3 years after the last one we covered Air conditioners, humidifiers, dehumidifiers, purifier Safety, hygiene, convenience, and exercise equipment and supplies Lifts, such as seat, chair or van lifts Any charges in excess of the $25,000 Standard Option lifetime limitation for covered durable medical equipment Computer devices to assist with communication Computer programs of any type Other items that do not meet the definition of durable medical equipment	All charges	All charges
Home health services
Private duty nursing care for covered services of a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or Christian Science nurse when: prescribed by the attending physician; The physician indicates the length of time the services are needed, and The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services. Benefits are limited to $10,000 per person per calendar year under High Option and $5,000 per person per calendar year under Standard Option.	PPO: 10% of the Plan allowance and all charges after the Plan has paid $10,000 Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $10,000	PPO: 15% of the Plan allowance and all charges after the Plan has paid $5,000 Non-PPO: 50% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $5,000
Not covered: Home health aide services Inpatient private duty nursing Nursing care requested by, or for the convenience of, the patient or the patient's family Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication Any charges in excess of the $10,000 High Option or $5,000 Standard Option plan limitation for covered private duty nursing care	All charges	All charges
Chiropractic
Services of a chiropractor, such as manipulation and X-rays Benefits are limited to $500 per person, per calendar year.	PPO: 10% of the Plan allowance and all charges after the Plan has paid $500 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $500	PPO: 15% of the Plan allowance and all charges after the Plan has paid $500 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $500
Alternative treatments
Acupuncture by a doctor of medicine, doctor of osteopathy, or licensed acupuncturist for pain relief Benefits are limited to $500 per person, per calendar year for all covered services and supplies.	PPO: 10% of the Plan allowance and all charges after the Plan has paid $500 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $500	PPO: 15% of the Plan allowance and all charges after the Plan has paid $500 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $500
Not covered: Naturopathic practitioner Massage therapist Any charges in excess of the $500 plan limitation for covered acupuncture and chiropractic services Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas; see page 9	All charges	All charges
Educational classes and programs
Smoking Cessation - Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs	PPO: 10% of the Plan allowance and all charges after the Plan has paid $100 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $100	PPO: 15% of the Plan allowance and all charges after the Plan has paid $100 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount and all charges after the Plan has paid $100
Diabetes self management	PPO: 10% of the Plan allowance Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount	PPO: 15% of the Plan allowance and all charges after the Plan has paid $100 Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

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