Page 52 - Aegion Value Plan SPDs
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e. Type 2 Diabetes Mellitus;
f. Cholesterol;
g. Child and Adult Obesity.
2. Immunizations for children, adolescents, and adults recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention;
3. Preventive care and screenings for infants, children and adolescents as provided for in the
comprehensive guidelines supported by the Health Resources and Services Administration; and
4. Additional preventive care and screening for women provided for in the guidelines supported by the
Health Resources and Services Administration, including the following:
a. Women’s contraceptives, sterilization procedures and counseling. Coverage includes
contraceptive devices such as diaphragms, intra uterine devices (IUDs) and implants.
b. Breastfeeding support, supplies and counseling. Benefits for breast pumps are limited to one pump
per pregnancy.
c. Gestational diabetes screening.
You may call Member Services using the number on Your Identification Card for additional information
about these services. (or view the federal government’s web sites,
http://www.healthcare.gov/center/regulations/prevention.html, http://www.ahrq.gov, and
http://www.cdc.gov/vaccines/acip/index.html.)
Diabetes self management training is covered for an individual with insulin dependent diabetes, non-insulin
dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition
when:
Medically Necessary;
Ordered in writing by a Physician or a podiatrist; and
Provided by a Health Care Professional who is licensed, registered, or certified under state law.
For the purposes of this provision, a "Health Care Professional" means the Physician or podiatrist ordering
the training or a Provider who has obtained certification in diabetes education by the American Diabetes
Association.
Physician Office Services
Office Services include care in a Physician’s office that is not related to Maternity and Mental Health
Conditions, except as specified. Refer to the sections entitled Maternity Services and Mental
Health/Substance Abuse Services for services covered by the Plan. For Emergency Accident or
Medical Care refer to the Emergency Care and Urgent Care section.
Office visits for medical care and consultations to examine, diagnose, and treat an illness or injury
performed in the Physician’s office. Office visits include injections including allergy injections.
Diagnostic Services when required to diagnose or monitor a symptom, disease or condition.
Surgery and Surgical services including anesthesia and supplies. The surgical fee includes normal post-
operative care.
Therapy Services for Physical Medicine Therapies and Other Therapies when rendered in the office of a
Physician or other professional Provider.
Inpatient Services
Inpatient Services do not include care related to Maternity and Mental Health Conditions, except as
specified. Refer to the sections entitled Maternity Services and Mental Health/Substance Abuse
Services for services covered by the Plan. Inpatient Services include:
52
f. Cholesterol;
g. Child and Adult Obesity.
2. Immunizations for children, adolescents, and adults recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention;
3. Preventive care and screenings for infants, children and adolescents as provided for in the
comprehensive guidelines supported by the Health Resources and Services Administration; and
4. Additional preventive care and screening for women provided for in the guidelines supported by the
Health Resources and Services Administration, including the following:
a. Women’s contraceptives, sterilization procedures and counseling. Coverage includes
contraceptive devices such as diaphragms, intra uterine devices (IUDs) and implants.
b. Breastfeeding support, supplies and counseling. Benefits for breast pumps are limited to one pump
per pregnancy.
c. Gestational diabetes screening.
You may call Member Services using the number on Your Identification Card for additional information
about these services. (or view the federal government’s web sites,
http://www.healthcare.gov/center/regulations/prevention.html, http://www.ahrq.gov, and
http://www.cdc.gov/vaccines/acip/index.html.)
Diabetes self management training is covered for an individual with insulin dependent diabetes, non-insulin
dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition
when:
Medically Necessary;
Ordered in writing by a Physician or a podiatrist; and
Provided by a Health Care Professional who is licensed, registered, or certified under state law.
For the purposes of this provision, a "Health Care Professional" means the Physician or podiatrist ordering
the training or a Provider who has obtained certification in diabetes education by the American Diabetes
Association.
Physician Office Services
Office Services include care in a Physician’s office that is not related to Maternity and Mental Health
Conditions, except as specified. Refer to the sections entitled Maternity Services and Mental
Health/Substance Abuse Services for services covered by the Plan. For Emergency Accident or
Medical Care refer to the Emergency Care and Urgent Care section.
Office visits for medical care and consultations to examine, diagnose, and treat an illness or injury
performed in the Physician’s office. Office visits include injections including allergy injections.
Diagnostic Services when required to diagnose or monitor a symptom, disease or condition.
Surgery and Surgical services including anesthesia and supplies. The surgical fee includes normal post-
operative care.
Therapy Services for Physical Medicine Therapies and Other Therapies when rendered in the office of a
Physician or other professional Provider.
Inpatient Services
Inpatient Services do not include care related to Maternity and Mental Health Conditions, except as
specified. Refer to the sections entitled Maternity Services and Mental Health/Substance Abuse
Services for services covered by the Plan. Inpatient Services include:
52
