Page 52 - 2022 Large Group benefits

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What’s not covered
• • Services Services not medically necessary
• • • Services Services or or or supplies that are experimental or or or investigative except routine costs associated with qualifying clinical trials
• • • Hearing aids aids hearing hearing hearing examinations/tests for the prescription/fitting of hearing hearing hearing aids aids and and cochlear electromagnetic hearing hearing hearing devices
• • • Assisted fertilization fertilization techniques such as in in in in in in vitro fertilization fertilization GIFT and ZIFT
• • • Reversal of voluntary sterilization
• • • Expenses related to organ donation for non-employee recipients
• • • Music therapy therapy therapy therapy equestrian therapy therapy therapy therapy and hippotherapy
• • • Sex therapy therapy therapy therapy or or or or or other other forms of of of counseling for for for the the the the the the the the treatment treatment of of of sexual dysfunction when performed by a a a a a a a a a a a a a a a a a non-licensed sex sex therapist
• • • Routine foot care unless medically necessary
or or or or or or or or associated with the the the the the treatment treatment of of of of diabetes
• • • Foot orthotics orthotics except for for orthotics orthotics and podiatric appliances required for for the the the prevention of of complications associated associated with with diabetes
diabetes
• • • Cranial prosthesis including wigs intended to replace hair loss
• • • Alternative therapies/complementary medicine such such as as as reiki massage
• • • Routine physical exams for for non-preventive purposes such such as as as insurance or or or or or employment employment applications college or or or or or premarital examinations • • • Immunizations for for travel or or or or or employment • • • Services or or or or or or supplies supplies payable under workers’ compensation motor vehicle insurance or or or or or or other legislation of similar purpose • • • Cosmetic services/supplies
• • • Bariatric or obesity surgery
• • • Outpatient private duty nursing
• • Drugs not appearing on on on the the Drug Drug Formulary Formulary except except where an an an exception has been granted pursuant to the the Formulary Formulary Exception Policy
Benefits that require preapproval
Additional approval
approval
from Independence may may be be required before your your employees employees may may receive certain tests procedures and medications When your your employees employees need services services that require require preapproval
their primary care physician physician or or or or or or provider contacts the the the Care Management and and and Coordination (CMC) team team team and and and submits information to support the the the the the request for for for services services The The CMC CMC CMC team team team made up up of of of physicians and and and nurses evaluates the the the the the proposed plan of of of care for for for for for for payment of of of benefits The The CMC CMC CMC CMC team team team team will notify your employees’ physician/provider if if the the the the the services are are are approved for for for for coverage coverage If the the the the the CMC CMC team team does does not not not not have sufficient information information or or or or or or or or the the the the the information information evaluated does does not not not not support coverage coverage your your employee employee and his or or or or or or or or her physician/provider are are notified in in in in in in writing of the the the the the the the the decision decision Employees or or or or or or or or a a a a a a a a a a a a a a a a a a a a a a a a a provider provider provider acting on on on on on on their behalf may may appeal appeal the the the the the the the decision decision At any time during the the the the the the the evaluation process or or or or or or the the the the the the the appeal appeal the the the the the the the provider provider provider or or or or or or your your employee employee may may submit additional information to support the the the request Additional benefits and exclusions
The The information in in in in this brochure represents only a a a a a a a a a a a a a a a a a a a partial listing of of benefits and and exclusions
exclusions
of of the the the the plans Benefits and and exclusions
exclusions
may may be be be be further defined by the the the the medical policy The The managed care care care care plan plan may may not cover cover all all health health care care care care expenses Members should read their contract member member handbook or or or or benefits booklet carefully to to determine which health health care care care care services are are are are are covered
If more information is is is is needed members can call 1-800-ASK-BLUE (1-800-275-2583) Information in in in this brochure is is is is current at at at at the time of publication and and is is is is subject to to change Additional information Your broker consultant or or Independence account executive can provide information about the following upon request: • Factors that may affect changes in premium rates*
• Benefits and premiums for for all the health benefit plans for for which you qualify *
Independence reserves the right to change premium rates