Medical Benefits

The following is a brief summary of medical benefits covered and some of the more significant restrictions and exclusions. All medical benefits are only covered to the extent they are deemed to be Medically Necessary, not in excess of Reasonable and Customary Charges, and not Experimental, or Investigational.

Alternative Therapy

Alternative Therapy includes:

• Acupuncture
• Biofeedback
• Chiropractic treatment

Acupuncture is covered only when performed by a medical doctor or state Certified Acupuncturist. The only exception applies to the State of Nevada where it is also covered when performed by a Doctor of Traditional Chinese Medicine.

Chiropractic treatment for Dependent Children under age 16 is not covered.

There is a combined limit of 26 visits per person per calendar year for Acupuncture and Chiropractic treatment.

Ambulance

If it is Medically Necessary, the Plan covers professional ambulance service to the nearest hospital for care and treatment of an injury or sickness. Air ambulance service is also covered when Medically Necessary to transport a patient to the closest treatment center. Transportation for the patient’s convenience is not covered.

Durable Medical Equipment (DME)

The Plan covers the rental of a wheelchair, hospital-type bed or other durable medical equipment, used exclusively for the therapeutic treatment of injury or sickness.

If you require DME for a long period of time and the rental price is expected to exceed the purchase price, you should consider purchasing the equipment. A doctor’s prescription and approval by the Board of Trustees is required.

Continuous Positive Airway Pressure (CPAP) Devices

CPAP devices are covered with a diagnosis of obstructive sleep apnea (OSA) that has been documented by an attended, facility-based polysomnogram (sleep study) that meets one of the following criteria:

• The Apnea-Hypoapnea Index (AHI) is greater than or equal to 15 events per hour
• The Apnea-Hypoapnea Index (AHI) is from 5 to 14 events per hour with documented symptoms of either:
  1. Excessive daytime sleepiness, impaired cognition, mood disorders or insomnia
  2. Hypertension, ischemic heart disease, or history of stroke

Continued coverage of a CPAP device beyond three months of therapy will be handled by the Case Management Department who will contact the patient 61 days after the initial authorization to determine the patient’s progress. Findings from that follow-up will dictate the continued approval of the CPAP for purchase and/or coordinating the return of the device to the DME company.

Continuous Passive Motion (CPM) Machines

CPM machines are covered as DME to improve range of motion in any of the following circumstances:

1. During the postoperative rehabilitation period for Participants who have received a total knee arthroplasty or replacement as an adjunct to on-going physical therapy.
2. Participant who has had an anterior cruciate ligament repair until the Participant is participating in an active physical therapy program.
3. Participants undergoing surgical release of arthrofibrosis/adhesive capsulitis or manipulation under anesthesia of any joint: (knee, shoulder, and elbow the most common) until the Participant is participating in an active physical therapy program.
4. To promote cartilage growth and enhance cartilage healing during the non-weight bearing period following any of the following until the Participant begins the weight bearing phase of recovery:
   • Surgery for intra-articular cartilage fractures
   • Chondroplasties of focal cartilage defects
   • Surgical treatment of osteochondritis dissecans
   • After abrasion arthroplasty or micro-fracture procedure
   • Treatment of an intra-articular fracture of the knee (e.g., tibial plateau fracture repair)
   • Autologous chondrocyte transplantation
5. Participants who have undergone certain surgeries and may not benefit optimally from active physical therapy. This includes Participants with reflex sympathetic dystrophy, Dupuytren’s contracture, extensive tendon fibrosis, or mental and behavioral disorders.
6. Participants who are unable to undergo active physical therapy.

When the CPM machine is used for surgical rehabilitation, the use of the device must commence within two days following surgery to meet Medical Necessity guidelines. Although the usual duration of CPM machines is 7 to 10 days, up to three weeks of CPM therapy may be considered Medically Necessary upon individual consideration. Use of the CPM machine beyond 21 days post-op is not supported by the medical literature and there is insufficient evidence to justify the use of these devices for longer periods of time or for other applications.

The Plan considers CPM machines experimental and investigational for all other purposes.

Examples of DME Expenses Not Covered

Benefits will not be payable for:

• Handrails
• Wheelchair batteries or any other batteries used with DME
• Over-the-bed tables
• Hot tubs, spas, Jacuzzi’s, pools
• Air conditioners
• Special auto equipment, such as van lifts
• Exercise equipment (treadmill, rowing machine, etc.)
• Recliners
• Mattresses

Hearing Aid Benefit

All Participants and their Eligible Dependents are eligible for the hearing aid benefit. This includes those in the PPO Plan and those enrolled in an HMO.

The Plan will pay a maximum of $1,000 per ear for the purchase of a hearing aid or for repair and batteries after satisfaction of the deductible. Benefits for new hearing aids, repairs and batteries are covered once every three years.

Home Health Care/Registered Nurse

When skilled nursing or home health care is required in the home, you are urged to check with the Fund Office to determine if the services qualify for coverage.

Skilled nursing and home health care must be ordered by a medical doctor, and the duties to be performed by the nurse(s) must be described. Home health care must be provided by a licensed Home Health Agency. Situations that require housekeeping and meal preparation are not covered even if nursing has been prescribed by a doctor. Home health care and registered nurse visits will be combined. Contact Anthem’s Utilization Management department by calling 800-274-7767 for assistance in coordinating this type of care. Home health services are limited to 10 visits per calendar year for treatment within 90 days of a confinement of at least 3 days.

Immunizations and Flu Shots

Most immunizations are covered by the Plan. This includes immunizations for adults and Dependent children.

The following vaccines are available with no co-payment at local CVS pharmacies:

• Seasonal Influenza
• Zoster (shingles)
• Tetanus, Diphtheria Toxoids, Pertussis
• Hepatitis A & B
• Measles, Mumps, Rubella, Varicella
• Pneumococcal (pneumonia)
• Human Papillomavirus
• Meningococcal

Infertility/Fertility Treatment

Infertility or sterility is not in itself a bodily illness and, therefore, is not generally covered by the Plan.

However, if the infertility is caused by an organic illness, the treatment of the underlying illness is covered.

The Plan will pay for the initial exam and diagnostic services necessary to determine infertility or sterility. However, the Plan will not pay for services performed to treat the infertility or sterility. Some of the non-covered services are:

• Artificial insemination
• Low tubal transfers
• In-Vitro Fertilization*
• Fertility Drugs
• Embryo Transplant
• Gamete Intrafellopian Transfer (GIFT)
• Reversal of elective sterilization unless medically necessary

^*The Plan does not cover any charges related to In-Vitro Fertilization unless the direct cause of the sterility is testicular cancer, in which case the Plan will pay up to $6,000 per program or $3,000 per “cycle” with a limitation of two cycles of treatment.

Maternity Benefits

Maternity benefits are provided for the pregnancy of a Spouse, Dependent or Participant on the same basis as any other illness or disability. (See Hospital Benefits.)

Care of Newborns

All hospital services and supplies necessary for the care of a newborn child during hospital confinement, including routine nursery care, will be paid in accordance with the Plan’s Hospital Benefits. The Participant must be eligible at the time of service for these benefits to be provided.

Adoption

The Plan will provide medical and hospital benefits toward charges for the birth of a child who is in the process of being adopted by the Participant. The Plan will not cover the birth mother’s charges. Adoption proceedings usually take 6 to 12 months before the adoption becomes final. Therefore, the Plan will require copies of documents from the attorney handling the adoption or from the court showing that the adoption is in progress. The child will be covered from the day he or she begins to live with the Participant.

Newborn’s and Mother’s Health Protection Act (NMHPA)

The Plan complies with a federal law that prohibits restricting benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, this Plan does not require that a health care practitioner obtain authorization from the Plan (or its utilization review company) for prescribing a length of stay up to 48 hours (or 96 hours following a cesarean section).

Organ Transplants

An “Organ” is a somewhat independent part of the body that performs a special function or functions. The Plan will cover all expenses related to the transplantation of an organ, including patient screening, organ procurement and transportation of the organ, patient and/or donor, surgery for the patient and donor, follow-up care in the home or a hospital provided the procedure is medically necessary and not deemed experimental or investigational. This transplant benefit is available only if the transplant recipient is eligible under the Plan at the time of surgery. Donor related expenses will only be covered if the donor has no other health insurance coverage for the transplant procedure. The Plan will not cover expenses for transportation of surgeons or family members. If the individual is covered by Medicare, and the Plan provides secondary coverage for that individual, no benefits will be provided by the Plan unless the transplant center is approved by Medicare. Immunosuppressant drugs are covered under the Plan’s Prescription Drug Benefit. The Plan does not consider a bone marrow transplant to be an organ transplant. Benefits may be available under the general benefit provisions of the Plan.

Participants enrolled in an HMO must utilize their HMO plan for these services.

Orthotics – Foot

Foot orthotics are external devices, other than casts, made especially for each individual person to support or correct a diseased or injured foot. Foot orthotics are covered only once every 12 months for adults and once in a period of 6 months for children under age 19. All foot orthotics must be custom-made and molded to the patient’s foot. Custom-made foot orthotics are covered when prescribed by a physician and prepared by a qualified health professional. Casting is paid under surgery benefits.

Walking Boots

A walking boot is a type of medical shoe used to protect the foot and ankle after an injury or surgery. The boot can be used for broken bones, tendon injuries, severe sprains, or shin splints. For walking boots that are prescribed by a doctor, the Plan will pay 90% of the Contract Rate for PPO network claims and 70% of Reasonable and Customary charges for non-network claims with a benefit maximum of $225 per claim, subject to deductible.

Physician Care

PPO Network

The Plan pays 90% of the Contract Rate after satisfaction of the deductible. You must pay a $20 co-payment plus 10% of the Contract Rate. You are also responsible for any services not covered by the Plan. For consultations, you are responsible for any contract amount that exceeds the Plan’s $150 consultation maximum. Also, for this benefit, you must be referred by another physician or other appropriate medical professional for an opinion or advice regarding a specific medical condition. The request for consultation or referral must be documented in your medical record and the consulting physician must provide a written report to the referring physician. If these requirements are not met, the charges for the initial consultation will be paid at a maximum of $15 per consultation after satisfaction of the deductible.

PPO Non-Network

The Plan pays a maximum of $15 per visit after satisfaction of the deductible. For consultations with a specialist, the Plan will pay 70% of Reasonable and Customary charges up to a maximum of $150 after satisfaction of the deductible.

Preventive Health Services – PPO Network Providers Only

Federal law requires this Plan to cover certain preventive services received from PPO Network providers with no deductible, co-payments or coinsurance. The Plan will cover these services whether they are performed separately or in the course of an annual physical. However, to avoid cost sharing, the primary purpose of the office visit must be for preventive care. Many of these services are provided during a routine physical or well-child exam.

Prosthetic Appliances

A prosthetic appliance is an artificial replacement for a missing body part, such as an artificial leg. If a natural limb or eye is lost while the patient was eligible under the Plan, the Plan will provide coverage for the artificial replacement of the lost limb or eye. A second artificial limb to replace an initial artificial limb may be covered if approved Anthem’s Utilization Management department. If a Dependent Child requires replacement of a prosthesis due to growth, each replacement will be a covered expense. Repairs and replacements of prosthetic appliances are subject to approval by the Fund Office.

Routine Physical Exam

The Plan will pay for physician charges incurred in connection with a routine physical exam once in any one year period as follows:

• PPO Network: The Plan will pay 90% of the Contract Rate, up to a maximum of $175 after satisfaction of the deductible. See pages 26-27 for Covered Preventive Services.
• PPO Non-Network: The Plan will pay 70% of Reasonable and Customary charges, up to a maximum of $150 after satisfaction of the deductible.

Benefits are not payable under the Routine Physical Exam benefit for:

• Diagnosis or treatment of any injury or illness Any examination of the teeth or gums
• Adoption or employment physicals or commercial driver’s license (CDL) examinations

Speech Therapy

The Plan will pay for speech therapy only if the following conditions are met:

• The treatment must be certified by a referring physician as medically necessary.
• The therapy must be given by, or under the direct supervision of, a certified or licensed Speech Pathologist.

PPO Network

The Plan pays 90% of the Contract Rate, subject to a $20 co-payment per visit, after satisfaction of the deductible.

PPO Non-Network

The Plan pays a maximum of $15 per visit after satisfaction of the deductible.

Substance Abuse/Chemical Dependency Treatment

Effective January 1, 2022, these benefits are provided through CBH.

The Plan will pay as follows:

Supplies

Supplies are items that are Medically Necessary for the therapeutic treatment of an illness or injury.

Some examples of supplies that are not covered by the Plan are:

• Ace bandages
• Heating pads
• Alcohol swabs
• Back or neck pads, cushions or pillows
• Incontinence pads or diapers
• Sports braces or supports
• Nutritional supplements

Please contact the Fund Office for further information.

Cosmetic Surgery

The term “Cosmetic Surgery” means surgery that is performed merely for the purpose of improving the appearance of an individual. The Plan does not cover Cosmetic Surgery unless the surgery being done is to repair or alleviate disfigurement resulting from an accident or for the correction of a congenital defect in a Dependent Child or for breast reconstruction following cancer-related mastectomy.

Weight Control Programs

The Plan will cover most of the charges for weight control programs if the patient meets the following requirements:

• The patient must have a Body Mass Index (BMI) greater than or equal to 30 and have serious medical conditions
• The patient must have remained “morbidly obese” for five consecutive years as documented in the patient’s medical records
• The patient must have a serious medical complication of obesity such as uncontrolled diabetes, uncontrolled hypertension, Pickwickian Syndrome (or hypoventilation), a reduced rate and depth of breathing, or crippling degenerative joint disease requiring a need for replacement of the hip or knee.

The Plan does not cover nutritional supplements, special food, liquid or powdered food supplements or over-the-counter weight loss medications.

Well-Child Care

For Dependent Children younger than age 7, routine examinations are paid as follows:

• PPO Network: The Plan will pay 90% of the Contract Rate subject to a $20 co-payment per visit after satisfaction of the deductible.
• PPO Non-Network: The Plan will pay 70% of Reasonable and Customary charges to a maximum payment of $15 after satisfaction of the deductible.

For Dependent Children age 7 or older, the Plan will pay according to the Plan’s Routine Physical Exam benefit. For more service information, refer to Covered Preventive Services, Immunization benefit, and Vision Care Benefits for routine eye exams.

Revised 11/2024