In Detail... (cont'd)

ELIGIBLE MEDICAL EXPENSES

The Comprehensive PPO, Standard PPO, Safety Net PPO and POS options pay expenses that are considered eligible, medically necessary and within the URC limits, as determined by the claims administrator. You pay any deductibles, copayments, coinsurance and penalties associated with eligible expenses. You also pay any expenses that are not eligible and amounts that exceed URC limits. And, remember to obtain a referral from your PCP if you participate in the POS option.

The medical plan options pay benefits for these eligible services and supplies for enrolled employees and eligible enrolled dependents):

• Abortion.
  
  
• Allergy serum, when it is mixed by your physician and administered in the physician’s office. Allergy serum prescriptions filled by your pharmacist are covered by Caremark.
  
  
• Ambulance service to a local facility for a life-threatening condition or a condition that could cause serious harm to your body. The medical plan options also cover air ambulance service to the nearest appropriate facility when this service is medically necessary.
  
  There is no coverage under any of the medical plan options for ambulance use when there is no emergency.
  
  
• Anesthesia and its administration.
  
  
• Treatment of attention deficit disorder (ADD), as defined by the American Psychiatric Association, including physician visits and related therapy.
  
  ADD is covered under the medical plan options administered by Blue Cross Blue Shield and the mental health and substance abuse benefits administered by ValueOptions. To speed the process of specialist or facility referrals and reimbursement of eligible expenses, you should seek treatment for ADD from ValueOptions first. Contact ValueOptions directly to arrange treatment for ADD.
  
  
• Autologous chondrocyte (ACO) implantation surgery (joint replacement therapy).
  
  
• Biological serum (such as vaccines and medicines, and other injectables), when it is mixed by your physician and administered in the physician's office. Caremark covers biological serum prescriptions filled by your pharmacist.
  
  
• Birth control: diaphragms (device and fitting), IUDs and Norplant (when procedure is performed in the doctor's office).
  
  
• Blood and blood plasma (except charges for the storage of your own blood).
  
  
• Cardiac rehabilitation phases I and 2, when received as a hospital outpatient within three months after your discharge from the hospital for a heart-related condition.
  
  
• Chiropractic services performed by a doctor of chiropractic (D.C.).
  
  
• Christian Science practitioner services.
  
  
• Cosmetic/reconstructive surgery and resulting implants to:
  • Restore a bodily function
    
  • Correct functionally significant congenital deformities
    
  • Correct conditions resulting from accidental injuries
    
    • Correct conditions resulting from scars, tumors, disease, or previous therapeutic processes
      
    • Restore breasts in connection with a mastectorny, specifically:
      
  
  
• Reconstruction of the breast on which the mastectorny was performed
  
  
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
  
  

Important notice about the Women's Health and Cancer Rights Act If you receive plan benefits in connection with a mastectomy, you are entitled to coverage for the following under the plan: Reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses and treatment for physical complications for all stages of a mastectomy, including lympheclemas (swelling associated with the removal of lymph nodes). The plan will determine the manner of coverage in consultation with you and your attending doctor. Coverage for breast reconstruction and related services will be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.

• Prostheses and treatment of physical complications for all stages of mastectomy, including lymphedemas.
  
  Cosmetic surgery performed mainly to change a person's appearance is not an eligible expense. However, medically necessary surgery that results from a previous cosmetic surgery is considered an eligible expense.
  
  
• Dental services to treat injuries to natural, rooted teeth (excluding damage to dental implants such as dentures, crowns and bridges) resulting from an accident, including services provided by a physician, dentist, or dental surgeon. This benefit includes replacement of the teeth and any related X-rays.
  
  For your expenses to be eligible, you must receive treatment within 12 months of the injury and you must remain enrolled in one of the medical plan options.
  
  
• Diagnostic X-ray and laboratory services, including charges for X-ray and laboratory services that a physician orders to diagnose an illness or injury.
  
  Under the Comprehensive PPO, Standard PPO and Safety Net PPO options, Pap smears and mammograms are eligible expenses when medically necessary or necessary to support a diagnosis. Otherwise, they are covered as preventive benefits.
  
  Routine Pap smears and mammograms are eligible expenses under the POS option only when ordered by your PCP. Your OB/GYN may order these routine services as part of your annual well-woman examination, but not under other circumstances.
  
  
• Dietary formulas for participants whose esophagus does not function and who require processed food with a feeding device, such as a feeding tube. Expenses for dietary formulas are also eligible for those with a diagnosis of phenylketonuria (PK-U) or another, similar disease.
  
  
• Durable medical equipment, including rental of equipment, such as a wheelchair, hospital bed, or oxygen equipment. To help save money, Blue Cross Blue Shield may authorize the purchase of equipment that you need for an extended period of time. The medical plan options also cover the repair and necessary maintenance of equipment if not provided under a manufacturer's warranty or a purchase agreement.
  
  
• Educational expenses related to diabetes, when medically necessary and prescribed by a physician, and approved by the claims administrator.
  
  
• Emergency room services for the treatment of emergencies. Benefits for emergency room treatment are deemed to be in- or out-of-network on the basis of whether your visit is an emergency They are not based on whether you visit a network facility.
  
  When your visit is for an emergency, you always receive in-network benefits. However, if your visit is not for an emergency, your benefits are determined by the medical plan option in which you are enrolled.
  
  For in- and out-of-network care, the $50 copayment is waived if you are admitted to the hospital after your emergency room visit.
  
  
• Hearing care.
  
  
• Hemodialysis.
  
  
• Heart pacemakers.
  
  
• Home health care services, including medical and nursing care (but not custodial care such as personal assistance with routine tasks).
  
  
• Hospice care for terminally ill patients.
  
  
• Hospital or surgical center expenses, including inpatient and outpatient charges for:
  
  • Semiprivate room and board
    
  • Services and supplies furnished by the hospital or surgical center for medical care, and for inpatient and outpatient services, including:
    
    • Drugs and medicines administered in the hospital
      
    • Electrocardiograms and basal metabolism tests
      
    • Medical equipment
      
    • Newborn care
      
    • Operating rooms
      
    • Oxygen and anesthesia materials
      
    • Recovery rooms
    • Treatment rooms
      
    • Use of blood transfusion and physiotherapy equipment
      
    • X-rays and laboratory tests.
      
      
  Except in a life-threatening emergency, you pay a $500 penalty if you are admitted to an out-of-network hospital.
  
  The $500 penalty applies only to out-of-network hospital admissions. It does not apply to emergency room treatment, outpatient treatment or laboratory services. Services from a professional (such as a physician, therapist or specialized nurse) are generally billed to you separately; they are not considered hospital charges and are not subject to the $500 penalty.
  
  
• Human organ and tissue transplants only when approved by Blue Cross Blue Shield and when performed at a Blue Cross Blue Shield Center of Excellence. Under the POS option, the procedure must be performed under the direction of and guidance from your PCP The medical plan options also cover the donor's charges and coordinate payment with the donor's own plan.
  
  
• Infertility services, including diagnostic services to determine the cause of infertility, and medical procedures required to correct a physical condition causing infertility.
  
  The medical plan options also cover impregnation procedures such as in vitro fertilization, artificial insemination and gamete intrafallopian transfers (GIFT), as well as related services such as hormone therapy, ultrasound, and lab work.
  
  The medical plan options do not cover donor's charges. Further, non-medically necessary administrative fees related to infertility services, such as egg and sperm donor search fees, and travel expenses also are not eligible.
  
  In addition, the medical plan options pay in-network benefits for fertility medications when prescribed for an infertility condition. In some cases, your physician may prescribe fertility medication for a condition that is unrelated to infertility. If so, Caremark - the prescription drug benefit administrator - covers the fertility medication.
  
  Benefits are subject to a $20,000 lifetime maximum for in-network and out-of-network services combined. After you reach the $20,000 lifetime maximum, your infertility coverage ends under the Vought Aircraft medical plan. The lifetime maximum includes reproductive technology, such as in vitro fertilization, and prescriptions to treat an infertility condition. (The lifetime maximum does not include fertility medications that are reimbursed through Caremark.)
  
  
• Inhalation therapy
  
  
• Mammography services.
  
  
• Mastectomy.
  
  
• Maternity including expenses for you or your enrolled spouse or child.
  
  According to federal law, hospital stays for services for the mother and newborn child cannot be less than 48 hours following a normal vaginal delivery or 96 hours following a caesarean birth, unless the attending physician, after consulting with the mother, discharges the mother or newborn child earlier. In addition, the physician is not required to precertify the maternity hospital stay if it falls within these limits.
  
  Expenses for a newborn baby of a dependent child are eligible only if the newborn becomes an eligible dependent under the Vought Aircraft medical plan.
  
  Expenses for midwives are eligible only when services are precertified by the claims administrator. The medical plan options pay out-of-network benefits for midwife services because there are no midwives in the network.
  
  
• Medical and surgical supplies, such as:
  • Blood and blood plasma
    
  • Casts and splints
    
  • Ostomy supplies (available from medical supply stores)
    
  • Oxygen and rental of equipment for its administration - up to the purchase price
    
  • Surgical dressings
    
  • Trusses, braces, and crutches.

• Occupational therapy when medically necessary and provided by a licensed occupational therapist.
  
  
• Oxygen.
  
  
• Physical and physiotherapy services, except maintenance physical therapy, as determined by the claims administrator. Eligible expenses include therapeutic treatment by a registered physiotherapist, when prescribed by a physician.
  
  
• Physicians' services, including physicians' fees for medical care or treatment, such as visits in the hospital, at home or in the physician's office.
  
  
• Physician assistant services, if accepted medical practice in your state. To determine if services provided by physician assistants are eligible in your state, call Blue Cross Blue Shield at 1-888-979-4514.
  
  
• Podiatry care (but not routine foot care).
  
  
• Prescription drugs.
  
  
• Preventive care, including immunizations, routine office visits, routine lab tests, and annual physical and well-woman exams. The medical plan options cover Pap smears, mammograms, colorectal screens and X-rays as preventive care, unless they are performed to support a diagnosis, in which case they are covered as a diagnostic service.
  
  Shots, pills and vaccinations that you receive in preparation for travel outside the U.S. are also considered preventive care and are subject to the benefit plan year maximum, if any, under your medical plan option. You pay all costs above the benefit plan year maximum.
  
  The Comprehensive PPO, Standard PPO and Safety Net PPO options cover adults and children (age 4 and over) for preventive care, with no deductible. The benefit plan year maximum is $200, combined for in- and out-of-network care. The POS option covers in-network preventive care with no maximum; out-of-network preventive care is not covered.
  
  
• Private duty nursing services, including care provided by a nurse (R.N., LYN., or L.VN.). The plan limits benefits to $1,000 per month. Precertification and case management are required.
  
  
• Prosthetics and orthotics, e.g., artificial limbs, eyes and larynx.
  
  
• Radiotherapy and chemotherapy services, including charges for treatment and related materials, equipment and facilities.
  
  
• Skilled nursing facilities, including charges for room, board and miscellaneous expenses related to the stay. Your admission must be recommended by your physician. The medical plan options pay benefits based on eligible expenses for a semiprivate hospital room and limit each stay to 60 days per condition. Precertification and case management are required.
  
  
• Speech therapy, including therapy by a qualified speech therapist, to:
  • Restore speech after a loss or impairment of a demonstrated previous ability to speak (except speech loss or impairment caused by a mental, psychoneurotic or personality disorder)
    
  • Develop or improve speech after surgery to correct a defect that existed at birth and impaired, or would have impaired, the ability to speak.
    
  
  
• Sterilization, including voluntary sterilization procedures such as tubal ligation and vasectomy.
  
  
• Surgery and surgical procedures, including:
  
  • Charges by a physician for performing a surgical procedure and for the physician's pre-operative and post-operative exams
    
  • Assistant surgeon's and/or anesthesiologist's charges for services required for the surgery
    
  • Charges for cutting, suturing and treating bums, correcting fractures, reducing dislocation, and manipulating joints under general anesthesia
    
  • Charges for performing electrocauterization, tapping (paracentesis), applying plaster casts, performing voluntary sterilization, performing endoscopy or injecting sclerosing solution.
    
  
  
• Temporomandibular joint (TMJ) syndrome, including medically necessary initial surgical consultation and surgical treatment of dysfunction of the temporomandibular joint. The medical plan options do not cover therapy (before or after surgery), appliances or the shortening or lengthening of the maxilla or mandible for cosmetic purposes or for correction of malocclusion.
  
  
• Urgent care facility services.
  
  
• Vision care.
  
  
• Well-child care, including charges for routine checkups and immunizations at the physician's office for children up to age four.
  
  Under the Comprehensive PPO, Standard PPO and Safety Net PPO options, children are covered for up to $250 per benefit plan year, combined for in- and out-of-network preventive care. The POS option pays 100% for wellchild care, after you pay a $15 copayment; there is no coverage for out-of-network care.
  
  
• Weight loss prescriptions, but only with a diagnosis of morbid obesity. Surgical methods of weight reduction are eligible if morbid obesity is still present after five years of unsuccessful attempts using nonsurgical methods. Surgical methods include vertical banded gastroplasty (stomach stapling) and gastric bypass surgery. Other methods require individual consideration by the Blue Cross Blue Shield Medical Director.
  
  
• Wigs, including the cost of a patient's initial wig; covered at 100% with no deductible (up to a lifetime maximum of $500) if:
  
  • The hair loss is a result of alopecia, chemotherapy or radiation treatment or other, similar conditions, and
    
  • The wig is recommended or prescribed by the patient's attending physician.

   

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