Health and Welfare Summary Plan Description

8.8 Covered Charges.

Benefits are payable only for Covered Charges. A Covered Charge is a fee or other expense for a charge that is the lesser of a Reasonable and Customary charge or contracted rate, is incurred by a Covered Individual, is Medically Necessary for a condition that is covered under the Plan, and is not excluded under Section 8.9. Covered Charges that satisfy these conditions may include:

  1. Acupuncturist. For up to a maximum of 30 visits per calendar year for charges of a licensed acupuncturist.

  2. Adult Immunizations. Charges for immunizations for adults. Benefits are limited to immunizations that are recommended by the American Academy of Family Physicians or the patient's Physician. Certain immunizations are considered Preventive Care services and will be covered without cost-sharing if provided by an in-network provider.

  3. Ambulance/Transportation. For transporting the patient to the most appropriate Hospital or skilled nursing facility where treatment is given and when Medically Necessary, and where transportation in any other vehicle could endanger your health. Emergency ambulance transportation in an airplane or helicopter to a hospital may be covered if such transport is (i) is needed immediately and rapidly and (ii) ground transportation cannot provide the necessary transportation with speed and immediacy. Some limited non-emergency ambulance transportation may be covered if you have a written order from your doctor stating that ambulance transportation is necessary due to your medical condition. The Plan will only cover ambulance services to the nearest appropriate medical facility equipped to provide the required treatment.

  4. Anesthesia. For anesthesia and its administration.

  5. Annual Physical. To the extent certain Preventive Care services are included in the annual physical, such services shall be covered without cost-sharing and without a monetary limit if provided by an in-network provider.

  6. Blood. For blood or blood plasma not replaced, including the storage of the patient's blood when approved or recommended by the attending Physician or surgeon.

  7. Cancer Treatment. For use of radium and radioactive isotopes and/or cancer chemotherapy treatment.

  8. Cataract Surgery. For contact lenses or eyeglasses and frames required immediately following and as a result of cataract surgery.

  9. Chiropractor. For up to a maximum of 30 visits per calendar year for charges by generally accepted chiropractic standards when treated by a licensed chiropractor.

  10. Colorectal Cancer Screening. The Plan will cover colorectal cancer screening, generally applying the same eligibility rules that Medicare applies to Medicare beneficiaries when determining eligibility for colorectal cancer screening. Those rules can be reviewed at For adults over age 50, colorectal cancer screening is a Preventive Care service

  11. Drugs. For drugs and medicine obtainable only upon the written prescription of a Physician and dispensed by a licensed pharmacist, including insulin and diabetic supplies (administered through Catamaran's prescription drug card program - see Section 8.4).

  12. Early Screenings. For the following early screenings, based on Medicare guidelines:


    Frequency for Normal Risk Participants

    Frequency for High Risk Participants

    Pap Smears and Pelvic Exams

    Once every 24 months

    Once every 12 months

    Prostate Cancer Screenings

    Once every 12 months for men age 50 and older

    Mammogram Screenings

    One baseline screening mammogram for women 35 to 39 years of age; once every 12 months for women 40 years and older

    Diagnostic mammograms when a screening mammogram shows an abnormality

  13. Injectable Drugs. For injectable drugs, including syringes and needles. (Some injectable drugs are covered through Catamaran's drug program. See Section 8.4.)

  14. Intensive Care or Coronary Care. For accommodations in an intensive care unit or coronary care unit which are in excess of the semiprivate rate, when required for the treatment of a critically ill or injured person.

  15. Laboratory Tests and X-Rays. Certain laboratory tests may be considered Preventive Care services.

  16. Skilled Nursing Facility (SNF). SNF Hospital Covered Charges are reimbursable after an in-patient Hospital confinement of at least 3 days, up to a maximum confinement is 100, reduced by the number of days of Hospital confinement. Successive Hospital confinements (including convalescent hospital confinements) will be considered a single confinement unless separated by a period of 30 days or the second confinement is due to a new accidental injury. Medicare eligibility guidelines for SNF coverage are applicable. This means you must submit a physician's certification that SNF care is necessary, you must be admitted to the SNF within 30 days following a minimum 3-day hospital stay, that you require daily skilled nursing or rehabilitation (as opposed to custodial care only) and the care is only available in a SNF on an in-patient basis. Only Medicare-certified SNF providers are covered providers for Medicare-eligible Participants.

    A Skilled Nursing Facility is a nursing facility that meets federal and state licensing standards, with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services. Skilled nursing care is care given or supervised by Registered Nurses who provide direct care, manage, observe and evaluate a patient's care; and teach the patient and his or her family caregiver.

  17. Maternity Charges. For maternity-related services for a Participant or Spouse, but excluding maternity charges incurred by a Dependent other than for complications of pregnancy. Charges due to elective abortion are not Covered Charges except where the life or health of the mother would be endangered if the fetus were carried to term, or those charges that directly result from complications of an abortion. Expenses for "well-baby" care are not covered, with the exception of a "well baby Physician's Hospital visits." For this purpose, "complications of pregnancy" means (i) conditions that require Hospital confinements (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy, or which are caused by pregnancy, and (ii) non-elective Cesarean section, ectopic pregnancy that is terminated, and spontaneous termination of pregnancy that occurs during a period of gestation in which a viable birth is not possible.
    1. Extended Maternity Coverage. A Participant or Spouse who is pregnant on the date of termination of her coverage will be entitled to the applicable benefits for covered expenses due to her pregnancy even though she may not be totally disabled on the date of termination provided (i) the pregnancy commenced while such individual was eligible for coverage under the Plan and (ii) such individual is not eligible for coverage under any other group plan providing similar benefits for the pregnancy.

    2. Coverage of Post-Delivery Hospital Stay. Charges for maternity-related care will be provided on the same basis as any other Illness, except that charges for in-patient Hospital treatment for childbirth delivery will be provided for the mother's newborn child for 48 hours following normal vaginal delivery and 96 hours following delivery by Caesarean section. The mother and newborn child may be discharged earlier than the above indicated time periods if (i) the treating Physician or Other Accredited Provider, in consultation with the mother, makes the decision to discharge the mother and child for an earlier time period, and (ii) a post discharge follow-up visit for the mother and newborn child is provided within 48-hours of discharge if prescribed by the treating Physician and the visit is provided by an Other Accredited Provider whose scope of practice includes postpartum care and newborn care, and may include parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal or neonatal physical assessments.
  18. Mental Health. Charges for inpatient hospital, outpatient facility, and professional services, including psychological testing, and behavioral health treatment, for mental health conditions. (See also Section 8.6(d).) In-network treatment is covered at 100% of the contracted PPO rate and out-of-network treatment is covered at 60% of Reasonable and Customary Charges.

  19. Nursing. Made by a registered nurse, a licensed vocational nurse or licensed practical nurse, for private duty non-custodial nursing service.

  20. Osteoporosis. For the treatment of osteoporosis, including all FDA-approved technologies, including bone mass measurement technologies as deemed medically appropriate by a Physician.

  21. Outpatient Facilities. For services rendered for out-patient surgery if the patient undergoes a surgical procedure which would normally be performed in a Hospital but which can be performed in an ambulatory out-patient surgical facility or a Physician's office. The patient has the right to choose between having the procedure performed in the ambulatory out-patient surgical facility, the Physician's office, or in the Hospital.

  22. Oxygen. For oxygen and purchase or rental of equipment for its administration. The benefit limit for rental will not exceed the purchase cost.

  23. Pre-admission and X-Rays. Made by a Hospital for pre-admission testing for diagnostic tests performed and x-rays taken, in the Hospital's out-patient department in connection with a scheduled Hospital admission for treatment of Injury or Illness covered by the Plan, provided tests are (i) made within 7 days prior to admission, (ii) ordered by the same Physician who ordered the admission, and (iii) the same tests that would have been ordered during the hospital confinement. If the scheduled admission is canceled or delayed, the benefit will still be paid if (i) the tests reveal a condition that requires treatment prior to the admission, (ii) a medical condition develops that delays the admission, (iii) a hospital bed is not available on the scheduled date of admission or (iv) the tests indicate that the admission is not necessary.

  24. Preventive Care Items and Services. The Plan pays 100% of all Preventive Care "in-network" Covered Charges. A complete list of the Preventive Care health services can be found at

    If a Preventive Care item or service is billed separately from an office visit, the office visit may not be treated as a Preventive Care Covered Charge. If a Preventive Care item or service and office visit are not billed separately and the primary purpose of the office visit is the delivery of the Preventive Care item or service, the office visit will be treated as a Preventive Care Covered Charge; but if the delivery of the Preventive Care item or service is not the primary purpose of the office visit, the office visit may not be treated as a Preventive Care Covered Charge. A Preventive Care item or service may not be treated as a Preventive Care Covered Charge until the first day of the Plan year beginning on or after the date on which the service or treatment is designated as a Preventive Care item or service.
    1. Preventive Care Items and Services for Children
      1. A single Physician's visit, including immunizations and laboratory services in connection with such visit, at approximately the following ages:
        1. birth;
        2. 2, 4, 6, 9, 12, 15 and 18 months of age; and
        3. 2, 3, 4, 5, 6, 8, 10, 12, 14 and 16 years of age;
      2. Alcohol and drug use assessments for adolescents;
      3. Autism screening for children at 18 and 24 months;
      4. Behavioral assessments for children of all ages;
      5. Blood pressure screening;
      6. Cervical dysplasia screening for sexually active females;
      7. Congenital hypothyroidism screening for newborns;
      8. Depression screening for adolescents;
      9. Developmental screening for children over age 3, and surveillance throughout childhood;
      10. Dyslipidemia screening for children at higher risk of lipid disorders;
      11. Flouride chemoprevention supplements for children without fluoride water source;
      12. Gonorrhea preventive medical for the eyes of all newborns;
      13. Hearing screening for all newborns;
      14. Height, weight, and body mass index measurements;
      15. Hematocrit or hemoglobin screening;
      16. Hemoglobinpathies or sickle cell screening for newborns;
      17. HIV screening for adolescents at higher risk;
      18. Immunization vaccines from birth to age 18;
      19. Iron supplements for children 6 to 12 months at risk of anemia;
      20. laboratory services in connection with routine physical examinations;
      21. Lead screening for children at risk of exposure;
      22. Medical history;
      23. Obesity screening and counseling;
      24. Oral health risk assessment for young children ages 0 to 10 years;
      25. Plenylketonuria (PKU) screening for newborns;
      26. Physician's services for routine physical examinations;
      27. Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk;
      28. Tuberculin testing for children at higher risk of tuberculosis; and
      29. Vision screening.
    2. Preventive Care Items and Services for Adults
      1. Abdominal aortic aneurysm one-time screening for men of specified age who have ever smoked;
      2. Alcohol misuse screening and counseling;
      3. Aspirin for adults of certain ages;
      4. Blood pressure screening;
      5. Cholesterol screening for adults of certain ages or at higher risk;
      6. Depression screening;
      7. Diet counseling for adults at higher risk for chronic disease;
      8. Type 2 diabetes screening for adults with high blood pressure;
      9. HIV screening for adults at higher risk;
      10. Immunization vaccines;
      11. Obesity screening and counseling;
      12. Sexually transmitted infection (STI) prevention counseling for adults at higher risk;
      13. Tobacco use screening for all adults and cessation interventions for tobacco users; and
      14. Syphilis screening for adults at higher risk.
    3. Preventive Care Items and Services for Women, including Pregnant Women
      1. Anemia screening on a routine basis for pregnant women;
      2. Bacteriuria urinary tract or other infection screening for pregnant women;
      3. BRCA counseling about genetic testing for women at higher risk;
      4. Breast cancer mammography screening every 1 to 2 years for women over 40;
      5. Breastfeeding comprehensive support and counseling and access to breastfeeding supplies for pregnant and nursing women;
      6. Cervical cancer screening for sexually active women;
      7. Chlamydia infection screening for younger women and women at higher risk;
      8. Contraception (FDA-approved methods, sterilization procedures, and patient education and counseling);
      9. Domestic and interpersonal violence screening and counseling;
      10. Folic acid supplements for women who may become pregnant;
      11. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at higher risk;
      12. Gonorrhea screening for all women at higher risk;
      13. Hepatitis B screening for pregnant women at their first prenatal visit;
      14. HIV screening and counseling for sexually active women;
      15. HPV DNA tests every 3 years for women with normal cytology results who are 30 or older;
      16. Osteoporosis screening for women over 60 depending on risk factors;
      17. Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk;
      18. Tobacco use screening and interventions, and expanded counseling for pregnant tobacco users;
      19. Syphilis screening for all pregnant women or women at higher risk; and
      20. Well-woman visits to obtain recommended preventive services.
  25. Professional Medical Services. For professional medical services of a Physician or Other Accredited Provider.

  26. Prosthetic Services and Appliances. For initial and subsequent post-mastectomy prosthetic devices and prosthetic appliances such as artificial limbs or eyes.

  27. Rental of Durable Medical Equipment. For the rental (not to exceed the purchase price) of durable medical equipment such as a wheelchair and hospital-type bed. Durable equipment means equipment or FDA-approved medical devices that are medically necessary to aid in recovery, mobility and/or the support of life. Such durable medical equipment must (i) be prescribed by the attending Physician, (ii) be designed for prolonged use and (iii) not be primarily used for non-medical purposes.

  28. Transplant Benefits. All transplant procedures must be preauthorized and no out-of-network expenses will be payable.
    1. Cornea, Kidney or Skin. Benefits are provided only for human organ transplant services rendered at contracting facilities and by contracting providers to the extent they are (i) provided in connection with the transplant of a cornea, kidney, or skin, when the recipient of such transplant is a Participant and (ii) services incident to obtaining the human organ transplant material from a living donor or an organ transplant bank.

    2. Special Procedures. Benefits are provided only for transplant services rendered at special transplant facilities, when the recipient of such transplant are Participants or Dependents, for the following:
      1. Human heart transplants;
      2. Human lung transplants;
      3. Human heart and lung transplants in combination;
      4. Human liver transplants;
      5. Human kidney and pancreas transplants in combination;
      6. Human bone marrow transplants;
      7. Pediatric human small bowel transplants;
      8. Pediatric and adult human small bowel and liver transplants in combination; and
      9. Services incident to obtaining the human organ transplant material from a living donor or an organ transplant bank.
        The following schedule summarizes amounts paid by the Plan for transplant expenses related to organ donor costs and travel.
        Benefit Description

        Plan Pays

        Additional Limitation and Explanations

        Organ donor costs per transplant


        Travel, lodging and meals allowance is for the transplant recipient and his or her immediate family travel companion (both parents, if patient under age 19). Transplants performed outside the Shared Advantage Transplant Program will not be covered, including any donor expenses or travel, lodging and meals related to the transplant.

        Travel, lodging and meals allowance per transplant


  29. Speaking Assistance. For prosthetic devices to restore a method of speaking for the patient incident to a laryngectomy, including the initial and subsequent prosthetic devices or installation accessories, as prescribed by the treating Physician, but will not include electronic voice producing machines.

  30. Stand-by Surgeon. For services by a stand-by surgeon when necessary due to the risk of the surgical procedure.

  31. Sterilization. Charges for sterilization of the reproductive system, including vasectomy and tubal ligation.

  32. Substance Abuse. Charges for the treatment of substance abuse conditions, including residential rehabilitation treatment centers. In-network treatment is covered at 100% of the contracted PPO rate and out-of-network treatment is covered at 60% of Reasonable and Customary Charges. Charges for medical detoxification are covered as medical, rather than substance abuse treatment benefits.

  33. Support. For initial truss, brace or support, cast splints, and crutches.

  34. Surgical. For surgical procedures whether or not stored blood is used.

  35. Tempo-mandibular Joint Dysfunction. For the treatment of Tempo-Mandibular Joint Dysfunction syndrome ("TMJ"), or any other treatment of the face, neck, or head is covered on the basis as any other treatment of the skeletal system. Charges for intra-oral prosthetic devices are excluded.

  36. Therapist. For charges of a licensed or registered physical therapist or occupational therapist. Contact the Plan Office for an evaluation before starting treatment since the number of visits may be limited depending upon the nature of the Illness or Injury. Claims will be referred to the Plan's medical review department or an independent medical reviewer to determine Medical Necessity and appropriate frequency of treatment based on information provided by the caregiver in most instances.

  37. Treatment. By a Hospital for out-patient and in-patient treatment. Covered Charges for in-patient treatment are limited to the Hospital's regular rate for semi-private accommodations. If the Hospital does not have semi-private accommodations, the Plan will pay 75% of the minimum daily charges for room and board.