5.14 PROFESSIONAL SERVICES AND SUPPLIES
Covered Expenses for professional services and supplies include:
- Services rendered by a Physician for medical treatment of an Illness or Injury. “Medical treatment” means services rendered by or in the presence of a Physician or through an online or telephone consultation with a Teladoc Physician. Benefits are provided for office, home, and Hospital visits.
- Office visit services performed by a chiropractor, up to a maximum of 15 office visits per calendar year.
- Acupuncture up to a maximum of 15 visits per calendar year, and Medically Necessary naturopathic services.
- Services of a Registered Nurse (R.N.), provided the services rendered are not custodial in nature and cannot be performed by a less qualified professional.
- Physical therapy, occupational therapy, massage therapy or cardiac rehabilitation services, when prescribed by and under the direction of a Physician. Benefits for rehabilitation services are limited to one visit per day, and do not include services which are primarily educational, sports-related, or preventive in nature (i.e., physical conditioning or exercise). Physical therapy, massage therapy and occupational therapy are limited to 20 visits per calendar year except for physical or occupational therapy that is Medically Necessary to
treat a spinal injury.
- Speech therapy when Medically Necessary to restore speech (the ability to express thoughts, speak words, form sentences) lost as a result of Illness or Injury. Speech therapy must be: (a) prescribed by and under the direction of a Physician, and (b) expected to result in significant improvement of speech function. Speech therapy prescribed for a speech delay (e.g. resulting from a congenital condition) or for a learning disability is not a Covered Expense. Speech Therapy is limited to 20 visits per calendar year.
- Diagnostic x-rays, radium or radioactive isotope therapy performed by a Physician or Radiologist, or diagnostic laboratory examinations performed by a Physician or pathologist. Benefits may also be payable for certain diagnostic tests under PREVENTIVE HEALTH CARE and PREADMISSION TESTING.
- Medically Necessary professional ambulance service to transport a Participant to or from the nearest medical facility where appropriate treatment can be given. A licensed air ambulance is considered a Covered Expense if it is determined that the location and nature of the Illness or Injury make a licensed air ambulance Medically Necessary. The Plan will not consider payment of charges in excess of those retail rates charged by its preferred provider for air ambulance services. The Plan’s preferred providers for these services in Alaska are Guardian or LifeFlight Air Ambulance.
- Administration of oxygen; casts, splints, and surgical dressings.
- Purchase or rental, up to the purchase price, of prosthetic devices, durable medical equipment and supplies. Covered Expenses are defined as:
- Prosthetic devices and braces (including surgically implanted devices and corrective appliances), excluding replacements or repairs; or
- Equipment and those supplies which are:
- ordered by a Physician, and
- usable only by the Patient, and
- of no further use when medical need ends, and
- not primarily for the comfort or hygiene of the Participant, and
- not for environmental control, and
- not for exercise, and
- manufactured specifically for medical use, and
- approved as Medically Necessary treatment, as determined by the Fund, and
- not for prevention purposes.
Any accrual of charges for the rental of medical equipment that is in excess of the normal purchase price for that medical equipment is not a Covered Expense. A device used specifically as a safety item or to affect performance primarily in sports-related activities is not a Covered Expense. Non-durable medical supplies including (but not limited to) elastic stockings, ace bandages, gauze and like products are not Covered Expenses.
- Services of a Physician (MD) or dentist (DDS or DMD) for treatment of accidental Injury to sound natural teeth if treatment is performed within six months of the date of the Injury. “Sound natural teeth” means natural teeth (not teeth that have been restored with crowns, fixed or removable prosthodontics) that are free of active or chronic clinical decay, that have at least 50% bony support, that are functional in the dental arch, and that have not been excessively weakened by previous dental procedures. Services to alter vertical dimension or to restore occlusion are not Covered Expenses.
- Services of a Physician or oral surgeon (DMD) for Covered Expenses for treatment of temporomandibular joint (TMJ) dysfunction. Related surgical services require pre-certification for medical necessity.
- The Plan will provide benefits for two appliances over a Participant’s lifetime.
- Covered Dental Expenses related to charges from a dentist (DDS or DMD) or oral surgeon are paid under the dental care benefits.
- Syringes and diabetic supplies, including lancets, strips and swabs which are obtained without a prescription but are necessary for the use of a prescription drug.