Blue PPO Standardized Gold - Statewide PPO Network - 53901AZ1490003 Health Insurance Plan

Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

The following bariatric surgery procedures are covered: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic sleeve gastrectomy (LSG) 1. The patient must have a body-mass index (BMI) greater than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components: a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. The member must be 18 years or older, or have reached full expected skeletal growth.

PPOs must cover medically necessary chiropractic visits.

Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.

Limit: 2.0 Visit(s) per Year

Limit of 2 dental check-ups & cleanings per calendar year.

Benefits are limited to one (1) manual or electric (not hospital grade) breast pump and breast pump supplies per member, per calendar year. Benefits are limited to one (1) set of new and four (4) replacement sets of compression garments for the treatment of lymphedema per member, per calendar year. Benefits are limited to one (1) wig and one (1) hairpiece per member, per calendar year.

Limit: 1.0 Item(s) per Year

Limit of 1 pair of glasses or contact lenses per calendar year.

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Limit: 60.0 Visit(s) per Year

Exclusions: Visit limit is separate from outpatient habilitation service limit. Excludes group therapy, private duty nursing, and custodial care.

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical, speech, occupational, cardiac, cognitive and pulmonary habilitation therapy for people with disabilities in a variety of inpatient and/or outpatient settings.

Limit: 1.0 Item(s) per Benefit Period

Exclusions: Excludes disposable hearing aids, ear molds, batteries or battery replacements for hearing aids other than cochlear implants.

Hearing aid devices limited to one per ear, per Calendar Year when determined to be medically necessary by the Medical Management Organization.

Limit: 42.0 Visit(s) per Year

Exclusions: Excludes respite care, custodial care, private duty nursing.

1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The home health agency delivering care must be certified within the state the care is received.; 4. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.

Exclusions: Excludes respite care.

The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.

Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel).

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes 3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia

Limit: 60.0 Visit(s) per Year

Exclusions: Visit limit is separate from habilitation service limit. Excludes group therapy, private duty nursing, and custodial care.

Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program. These services may include physical, speech, occupational, cardiac rehabilitation, cognitive and pulmonary rehabilitation therapy. Some services may be subject to copay instead of coinsurance. Visit limit is for all therapy types combined.

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Limit: 1.0 Exam(s) per Year

Benefits are limited to one (1) preventive physical exam per member, per calendar year, unless additional visits are necessary for the member to obtain all covered Preventive Services.

Exclusions: PCP visits out-of-network will be covered at the out-of-network cost.

24/7 online doctor visits available with BlueCare Anywhere ? see SBC for more information.

Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Custodial Nursing is not covered by the Plan.

Exclusions: Excludes biomechanical devices (external prosthetic device operated through or in conjunction with nerve conduction or other electrical impulses).

The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear.

Exclusions: Excludes cosmetic surgery and services except for breast reconstruction following medically necessary mastectomy.

Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed; 2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; 3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs. During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury and any other services required by law. Issuer covers reconstruction of congenital defects and birth abnormalities in accordance with its medical coverage guidelines and/or when required by applicable law. Issuer covers medically necessary complications of breast implants / pectoral implants.

Limit: 60.0 Visit(s) per Year

Exclusions: Excludes group therapy, private duty nursing, and custodial care.

Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits).

Limit: 60.0 Visit(s) per Year

Exclusions: Excludes group therapy, private duty nursing, and custodial care.

Visit limit is for multiple therapy types combined (PT, OT, ST, CT and Cardiac and Pulmonary Rehabilitative Visits).

Limit: 1.0 Visit(s) per Year

Limit of 1 routine vision exam per calendar year.

Limit: 90.0 Days per Year

90 combined SNF and inpatient extended rehabilitation days per calendar year.

Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Exclusions: Excludes facility charges for treatment provided by group homes, boarding schools, halfway houses, assisted living centers, shelters, foster homes or wilderness programs.

Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient's medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.

Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder.

Well Child visits and immunizations are covered as recommended by the American Academy of Pediatrics.