2007 - 2011 KA Generic HL Template

5/19/2017 2007_2011KAGenericHLTemplate
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Thisisonlyasummary.Ifyouwantmoredetailaboutyourcoverageandcosts,youcangetthecompletetermsinyourgroupplan
documents.Ifthereisadifferencebetweenthissummaryandyourplandocuments,thetermsofyourplandocumentswillapply.

Providers,thissummaryisformembers,toreviewthetermsofyourparticipationagreement,pleasevisitunitedhealthcareonline.com

SpecialServices
Whatyouwillfindinthissection:
AcupunctureServices
Chiropractic(Manipulative)Services
ClinicalTrials
CongenitalHeartDiseaseResourceServices(CHDRS)
CongenitalHeartDiseaseSurgeries
DentalServicesAccidentOnly
DentalAnesthesiaServices
DiabetesServices
DiabetesSupplies
DurableMedicalEquipment(DME)
ExperimentalorInvestigationalorUnprovenServices
HearingAids
HomeHealthCare
HospiceCare
KidneyResourceServices
MastectomyServices
OsteoporosisServices
OstomySupplies
PharmaceuticalServicesOutpatient
ProstheticSupplies
ReconstructiveProcedures
RehabilitationandHabilitativeServicesOutpatient
SmokingCessation
TemporomandibularJointServices
TransplantationServices
Wigs

Yourcostifyouuse Yourcostifyouuse
CommonMedicalEvent Limits&Exceptions
Networkbenefits OutofNetworkbenefits
AcupunctureServices $20copaypervisit 40%coinsurance,afteryou Limitedto12treatmentsperyear.
Theannualdeductibledoes paythedeductible
Whatareacupuncture notapply.
services?Atreatmentthat
usesthinneedlestocontrol
painandothersymptoms. Ispriorauthorization Ispriorauthorization
needed? needed?
Benefitsarecoveredfor: No No
Paintherapy.
Nausearelatedto
surgery,pregnancyor
chemotherapy.

Servicesmustbeperformedin
anofficesettingbyaprovider
whoispracticingwithinthe
scopeoftheirlicenseorwhois
certified:
DoctorofMedicine
DoctorofOsteopathy
Chiropractor
Acupuncturist

Wantmoreinformation?
Viewtheglossaryfor
definitions.

Chiropractic $20copaypervisit. 40%coinsurance,afteryou Limitedto24visitsperyear.
(Manipulative)Services Theannualdeductibledoes paythedeductible.
notapply.

https://www.myuhc.com/member/ibaagMedicalDetailLayout.do?pageName=Special_Services&bookmark=Rehabilitation_Services_Outpatient_Thera& 1/10
Whatarechiropractic Ispriorauthorization Ispriorauthorization

(manipulative)services? needed? needed?
Treatmentthatfocusesonthe No Yes
spineandnervoussystemto
helpwithpainandoverall Priorauthorizationis:
health. Gettingapprovalbycallingthe
numberlistedonyourhealth
Wantmoreinformation? planIDcardbeforeyoucan
Viewtheglossaryfor getmedicineorservices.
definitions.
WhendoIneedtocall?
5businessdaysbefore
scheduledservices
Assoonaspossiblefor
nonscheduledservices

Ifyoudontgetprior
authorization,youpay:
50%coinsurance

ClinicalTrials Theamountyoupayisbased Theamountyoupayisbased Nocoveragefor:
onwherethecoveredhealth onwherethecoveredhealth Costforinvestigationaldrugsor
Whatareclinicaltrials?A serviceisprovided. serviceisprovided. devices.
researchstudythattestsnew Costfornonhealthservices(for
treatmentsonpatients. Iftheoutofnetworkprovider example:travel/transportation)
doesnotagreetoacceptthe requiredforyoutoreceivethe
Wecoversomeroutinepatient networkrate,outofnetwork treatment.
costsforparticipationinan benefitsarenotcovered. Costformanagingtheresearch.
approvedclinicaltrialif: Itemsandservicesprovidedby
Youmeettherequirements Ispriorauthorization theresearchsponsorfreeof
toparticipateand needed? chargeforanypersonenrolledin
Youarereferredbya Ispriorauthorization Yes thetrial.
networkproviderwhohas needed?
saidbasedonmedicaland Yes Priorauthorizationis:
scientificinformationthe Gettingapprovalbycallingthe
clinicaltrialisappropriate Priorauthorizationis: numberlistedonyourhealth
foryourconditionand Gettingapprovalbycallingthe planIDcardbeforeyoucan
Youhavereceivedprior numberlistedonyourhealth getmedicineorservices.
authorizationfromus. planIDcardbeforeyoucan
getmedicineorservices. WhendoIneedtocall?
Whatisanapprovedclinical Assoonaspossible
trial?Aclinicaltrialthatis: WhendoIneedtocall?
Federallyfundedor Assoonaspossible Ifyoudontgetprior
approvedand
Conductedunderan Ifyoudontgetprior Allcharges
investigationaldrug
Allcharges
applicationreviewedbythe

FoodandDrug

Administration(FDA).

Forallotherclinicaltrialsthere
isnocoverage.

Viewtheglossaryfor
definitions.

AboutYourBenefits
CongenitalHeart TheCHDCentersofExcellenceNetworkgivespatientscarethatisplanned,coordinatedandprovided
DiseaseResource byateamofexpertswhospecializeintreatingCongenitalHeartDisease.

Services(CHDRS) Somebenefitsofthisprograminclude:
Accesstocosteffectivehighqualityhealthcare
Accesstocasemanagersandqualifiedproviders
Educationandcounseling

Participationinthisprogramisvoluntary.

NetworkbenefitsareavailableforpatientswhoreceivecareatadesignatedCHDCentersofExcellence
Networkfacility.

ContactCHDResourceServicesbyclickinghereorcalltollfreeat18889367246.TTYuserscan
dial711.

TravelandLodgingAssistanceisnotavailableaspartoftheCongenitalHeartDiseaseResource
Servicesprogram.

CongenitalHeart 20%coinsurance,afteryou 40%coinsurance,afteryou Networkbenefitsmustbereceivedat
DiseaseSurgeries paythedeductible. paythedeductible. adesignatedfacility.

Whatiscongenitalheart Ispriorauthorization Ispriorauthorization Ifyoudonotgotoadesignated
disease?Aheartproblemthat needed? needed? facility,benefitswillbeconsidered
No Yes outofnetwork.
apersonisbornwith.

Benefitsunderthissection Priorauthorizationis: Formoreinformation,seethe
Gettingapprovalbycallingthe CongenitalHeartDiseaseResource
include:
Facility numberlistedonyourhealth Servicessection.
planIDcardbeforeyoucan
Supplies
getmedicineorservices.
Equipment

Physicianservicesfor
WhendoIneedtocall?
anesthesiologists, Assoonasthepossibility
pathologistsandradiologists
ofsurgeryarises

Formoreinformationabout Ifyoudontgetprior
otherdoctorfees,seePhysician
FeesforSurgicalandMedical 50%coinsurance
Servicesbenefitsection.

Viewtheglossaryfor
definitions.

DentalServices 20%coinsurance,afteryou 20%coinsurance,afteryou
AccidentOnly paythedeductible. paythenetworkdeductible. Nocoveragefor:
Damagethatoccursasaresultof
Ispriorauthorization normalactivities,dailylivingor
Whatareaccidentaldental
services?Repairor Ispriorauthorization needed? extraordinaryuse
replacementofsoundnaturalor needed? Yesfollowuptreatment Dentalcarethatisrequiredto
Yesfollowuptreatment only. treattheeffectsofamedical
restoredteethduetoinjury.
only. condition,exceptasdescribed
Requirements Priorauthorizationis: underReconstructiveProcedures.
Priorauthorizationis: Gettingapprovalbycallingthe
Youmustcontactadoctor
Gettingapprovalbycallingthe numberlistedonyourhealth
ordentistwithin72hoursof
numberlistedonyourhealth planIDcardbeforeyoucan
theaccident.
planIDcardbeforeyoucan getmedicineorservices.
Treatmentmuststartwithin
3monthsoftheaccident.
WhendoIneedtocall?
Treatmentmustbe
WhendoIneedtocall? 5businessdaybefore
completedwithin12months 5businessdaybefore followuptreatmentbegins
oftheaccident.
followuptreatmentbegins

Ifyoudontgetprior
Wecover:
Ifyoudontgetprior authorization,youpay:
Emergencyexamination
authorization,youpay: Allcharges
Diagnosticxrays Allcharges
Rootcanalandrelated
services
Temporarysplintingofteeth
Simpleminimalrestorative
procedures(fillings)
Extractions
Posttraumaticcrownsif
theyaretheonlytreatment
available
Replacementoflostteeth

Viewtheglossaryfor
definitions.

DentalAnesthesia 20%coinsurance,afteryou 40%coinsurance,afteryou Benefitsarelimitedtoapersonthat:
Services paythedeductible. paythedeductible. Isunder7yearsofage
Isdevelopmentallydisabled,

Benefitsinclude: Ispriorauthorization Ispriorauthorization regardlessofage
needed? needed?
Generalanesthesia Yes Yes Hasahealthissuethatrequires

Facilitycharges generalanesthesia,regardlessof
Priorauthorizationis: Priorauthorizationis: age
Wantmoreinformation? Gettingapprovalbycallingthe Gettingapprovalbycallingthe
Viewtheglossaryfor numberlistedonyourhealth numberlistedonyourhealth Nocoveragefordiagnosisor
definitions. planIDcardbeforeyoucan planIDcardbeforeyoucan treatmentofdentaldisease.
getmedicineorservices. getmedicineorservices.

WhendoIneedtocall? WhendoIneedtocall?
5businessdaysbefore 5businessdaysbefore
scheduledservices scheduledservices
Assoonaspossiblefor Assoonaspossiblefor
nonscheduledservices nonscheduledservices

Ifyoudontgetprior Ifyoudontgetprior
authorization,youpay: authorization,youpay:
50%coinsurance 50%coinsurance

DiabetesServices Theamountyoupayisbased Theamountyoupayisbased None
onwherethecoveredhealth onwherethecoveredhealth
Whatisdiabetes?Adisease serviceisprovided. serviceisprovided.
thatmakesyourbloodsugar
levelhigherthanitshouldbe Ispriorauthorization Ispriorauthorization
andcancauseotherhealth needed? needed?
problems. No No

Wecover:
Educationandnutrition
therapyservicesorderedby
adoctor
Diabeticeyeexam
Preventivefootcare

Viewtheglossaryfor
definitions.

DiabetesSupplies Theamountyoupayisbased Theamountyoupayisbased None
onwherethecoveredhealth onwherethecoveredhealth
Whatisdiabetes?Adisease serviceisprovided. serviceisprovided.
thatmakesyourbloodsugar
levelhigherthanitshouldbe Ispriorauthorization Ispriorauthorization
andcancauseotherhealth needed? needed?
problems. No No

Wecover: InsulinPumps InsulinPumps
Bloodandurinetesting 20%coinsurance,afteryou 40%coinsurance,afteryou
strips paythedeductible. paythedeductible.
Glucosemonitors
Insulinsyringeswith Ispriorauthorization Ispriorauthorization
needles needed? needed?
Ketonetestingstripsand No Yes

tablets
Priorauthorizationis:
Lancetsandlancetdevices
Gettingapprovalbycallingthe
Cartridgesanddrawingup
forthevisuallyimpaired
planIDcardbeforeyoucan
Insulin
Insulinpumpandrelated

supplies WhendoIneedtocall?
Additionalsuppliesthatare Beforegettinganinsulin
determinednecessaryfor pumpthatexceeds$1,000
thetreatmentofdiabetes incost

Theabovediabeticsuppliesare Ifyoudontgetprior
coveredunderyouroutpatient authorization,youpay:
prescriptiondrugrider,except Allcharges
forinsulinpumpsandrelated
supplies.

Insulinpumpsandrelated
pumpsuppliesarecovered
underyourdurablemedical
equipment.

Viewtheglossaryfor
definitions.

DurableMedical 20%coinsurance,afteryou 40%coinsurance,afteryou Limitedtoasinglepurchaseofatype
Equipment paythedeductible. paythedeductible. ofDME(including
repair/replacement)every3years.

Whatisdurablemedical Ispriorauthorization Ispriorauthorization
equipment(DME)? required? required? Benefitsforspeechaiddevicesand
No Yes tracheoesophagealvoicedevicesare
Equipmentandsuppliesfor
limitedtoonedevice
medicalconditions.
Toreceivenetworkbenefits, Priorauthorizationis: duringtheentireperiodoftimeyou

DMEmustbe: youmustpurchaseorrentthe Gettingapprovalbycallingthe areenrolledintheplan.
orderedorprovidedbya DMEfromthevendorwe numberlistedonyourhealth
identifyorpurchaseitdirectly planIDcardbeforeyoucan Repair/replacementisonceevery3
doctorand
fromtheprescribingnetwork getmedicineorservices. years.
usedformedicalpurposes
doctor.

WhendoIneedtocall? Nocoverageforaddonsorupgrades
Thismayincludeequipment
BeforegettingDMEthat when:
like:oxygen,wheelchairs,
exceeds$1,000incost Theaddonorupgradeisfor
crutches,insulinpumps.Fora
convenienceonly.
completelistlookatyourplan
Ifyoudontgetprior Theaddonorupgradeisbeyond
documents.
authorization,youpay: whatsnecessarytomeetthe

Allcharges medicalneed.

Viewtheglossaryfor
Ifyourentorpurchaseequipment
definitions.
thatisanupgradeoraddonyouare

responsibleforthedifferenceincost.

Benefitsareavailableforrepairs
andreplacement,exceptwhen:
damageduetomisuseorabuse
lostorstolen

Experimental, Networkbenefitsarenot Outofnetworkbenefitsare Nocoverageforexperimental,
Investigationalor covered. notcovered. investigationalorunprovenservices.
Exceptionsmayapply.Formore
UnprovenServices information,callthenumberonyour
healthplanIDcard.
Whatareexperimentalor
investigationalservices?
Anythingthathasnotshownto
beeffective,establishedoris
stillbeinginvestigatedfora
medicalcondition.

Whatareunproven
services?Servicesthathave
notbeenproventobeeffective
forthetreatmentofamedical
condition.

Viewtheglossaryfor
definitions.

HearingAids 20%coinsurance,afteryou 40%coinsurance,afteryou Limitedto$2,500ineligible
paythedeductible. paythedeductible. expensesperyear.Benefitsare
Whatarehearingaids? limitedtoasinglepurchase(including
Hearingaidsareelectronic Ispriorauthorization Ispriorauthorization repair/replacement)perhearing
amplifyingdevicesdesignedto required? required? impairedearevery3years.
fixahearingimpairmentand No No
bringsoundmoreeffectively Nocoverageforboneanchored
intotheear.Ahearingaid hearingaidsexceptwhen:
consistsofamicrophone, Craniofacialanomaliesorabsent
amplifierandreceiver. earcanalskeepthemfromusing
awearablehearingaidor
Benefitsareprovidedforthe Hearinglosscannotbefixedbya
hearingaidandchargesfor wearablehearingaid.
fittingandtestingas Ifyoumeettheabovecriteria,
recommendedbyadoctor. benefitsarelimitedto1bone
anchoredhearingaidduringthetime
hiHealthInnovationsHearing youareenrolledunderthepolicy.
Programisavailabletoyou.For
moreinformationaboutthis Repairsand/orreplacementsarenot
program,calltollfreeat1 covered,exceptformalfunction.
8669266632.TTYuserscan
dial711.

Viewtheglossaryfor
definitions.

HomeHealthCare 20%coinsurance,afteryou 40%coinsurance,afteryou Limitedto100visitsperyear.1visit
paythedeductible. paythedeductible. equalsupto4hoursofskilledcare
Whatarehomehealthcare services.
services?Healthcareservices Ispriorauthorization Ispriorauthorization
apersonreceivesathome.This required? required? Thisvisitlimitdoesnotincludeany
caremustbeorderedbyyour No Yes servicethatisbilledforthe
doctorandprovidedbyahome administrationofintravenous
healthagency. Priorauthorizationis: infusion.
Whatiscovered? numberlistedonyourhealth Nocoveragefor:
Skilledcareprovidedbya planIDcardbeforeyoucan Custodialcare(nonskilledcare
licensedhealthcare getmedicineorservices. thathelpspeoplewithdailyliving
professional(forexample,RN) activitiesthatmostpeopleare
andisparttimeintermittent WhendoIneedtocall? abletodoforthemselves.Some
carethatis: 5businessdaysbefore examplesincludeeating,bathing
fewerthan7dayseach gettingservices and
week. Assoonaspossible dressing.)
fewerthan8hourseachday Privatedutynursing.
forperiodsof21daysor Ifyoudontgetprior Respitecareunlessinhospice.
less. authorization,youpay: ThisisdescribedunderHospice
50%coinsurance Care.
Wantmoreinformation? Personalcareattendants.
Viewtheglossaryfor
definitions.

HospiceCare 20%coinsurance,afteryou 40%coinsurance,afteryou None
paythedeductible. paythedeductible.
Whatishospicecare?
Hospicecareprovidescomfort Ispriorauthorization Ispriorauthorization
andsupportfortheterminallyill needed? needed?
inahospital,hospicefacilityor No Yes
home.
Priorauthorizationis:
Wecover: Gettingapprovalbycallingthe
Physical,psychological, numberlistedonyourhealth
social,spiritualandrespite planIDcardbeforeyoucan
carefortheterminallyill getmedicineorservices.
person.
Shorttermgriefcounseling WhendoIneedtocall?
forimmediatefamily 5businessdaysbefore
memberswhilethepatient beingadmitted
receiveshospicecare. Assoonaspossible

Wantmoreinformation? Ifyoudontgetprior
Viewtheglossaryfor authorization,youpay:
definitions 50%coinsurance

AboutYourBenefits
KidneyDisease OurChronicKidneyDisease(CKD)andKidneyResourceServices(KRS)programsprovideyou:
Programs
Nursesyoucanspeakwithtohelpmanageyourkidneydisease
Educationandcounseling
Helpwithfindingnetworkdialysiscentersanddoctors

Formoreinformationortospeaktoanurseadvocate,calltollfreeat18665617518.TTYusers
candial711.

MastectomyServices Theamountyoupayisbased Theamountyoupayisbased Thelengthofstaywillbedetermined
onwherethecoveredhealth onwherethecoveredhealth byyouandyourdoctor.
Benefitsinclude: serviceisprovided. serviceisprovided.
Mastectomies,including
lymphedema Ispriorauthorization Ispriorauthorization
Prostheticdevicesand needed? needed?
reconstructivesurgeryto Theauthorizationrequirement Theauthorizationrequirement
restoreandachieve isbasedonwherethecovered isbasedonwherethecovered
symmetry healthserviceisprovided. healthserviceisprovided.

Wantmoreinformation? Priorauthorizationis: Priorauthorizationis:
Viewtheglossaryfor Gettingapprovalbycallingthe Gettingapprovalbycallingthe
definitions. numberlistedonyourhealth numberlistedonyourhealth
planIDcardbeforeyoucan planIDcardbeforeyoucan

getmedicineorservices. getmedicineorservices.

CommonMedicalEvent Yourcostifyouuse Yourcostifyouuse Limits&Exceptions
OsteoporosisServices Theamountyoupayisbasedon Theamountyoupayisbasedon None
wherethecoveredhealth wherethecoveredhealth
Benefitsincludediagnosis, serviceisprovided. serviceisprovided.
treatmentandmanagementof
osteoporosis. Ispriorauthorization Ispriorauthorization
needed? needed?
*Forosteoporosisscreenings,see No No
thePreventiveCaresection.

Viewtheglossaryfordefinitions.

OstomySupplies 20%coinsurance,afteryou 40%coinsurance,afteryou Nocoveragefor:
paythedeductible. paythedeductible. deodorants
Wecover: filters
Pouches,faceplatesand Ispriorauthorization Ispriorauthorization lubricants
belts. needed? needed? tape
Irrigationsleeves,bagsand No No appliancecleaners
ostomyirrigationcatheters. adhesiveandremover
Skinbarriers. otheritemsnotlisted


PharmaceuticalProducts 20%coinsurance,afteryou 40%coinsurance,afteryou Iftheserviceisprovidedina
Outpatient paythedeductible. paythedeductible. doctorsoffice,additionalco
pays,deductibleorcoinsurance
Whatareoutpatient Ispriorauthorization Ispriorauthorization mayapply.
pharmaceuticalproducts? needed? needed?
Medicationsadministeredbya No No
medicalproviderandarecovered

underyourmedicalbenefits(not
underpharmacy).

Theseproductscanbegivenin:
Anoutpatientfacility
Doctorsoffice
Thehome


Prosthetics 20%coinsurance,afteryou 40%coinsurance,afteryou Wecoverthemostappropriate
paythedeductible. paythedeductible. prostheticdevicethatmeets
Externaldevicesthatreplacea yourminimummedicalneed.If
limborabodypart,limitedto: youchooseadifferentoneyou
limborabodypart,limitedto: youchooseadifferentoneyou
Artificialarms,legs,feetand Ispriorauthorization Ispriorauthorization areresponsibleforthe
hands needed? needed? differenceincost.
Artificialface,eyes,earsand No Yes
nose Limitedtoasinglepurchaseof
Breastprosthesis,including Priorauthorizationis: eachtypeofprostheticdevice
mastectomybrasand Gettingapprovalbycallingthe every3years.
lymphedemastockingsforthe numberlistedonyourhealth
arms planIDcardbeforeyoucanget Nocoveragefor:
Laryngectomydevices medicineorservices. Repairstoprostheticdevices
duetomisuse
Theprostheticdevicemustbe WhendoIneedtocall? Replacementofprosthetic
orderedorprovidedbyadoctor. Beforegettingprosthetic devicesduetomisuseorto
devicesthatexceeds$1,000 replacelostorstolenitems.
Benefitsunderthissectionare Electronicvoiceproducing
providedonlyforexternal Ifyoudontgetprior machines
prostheticdevicesanddonot authorization,youpay:
includeanydevicethatisfully Allcharges
implantedintothebody.
Laryngectomydevices:
Wantmoreinformation? Theamountyoupayisbasedon
Viewtheglossaryfordefinitions. wherethecoveredhealth
serviceisprovided.
Laryngectomydevices:
Theamountyoupayisbasedon Ispriorauthorization
wherethecoveredhealth needed?
serviceisprovided. Theauthorizationrequirement
isbasedonwherethecovered
Ispriorauthorization healthserviceisprovided.
needed?
Theauthorizationrequirement Priorauthorizationis:
isbasedonwherethecovered Gettingapprovalbycallingthe
healthserviceisprovided. numberlistedonyourhealth
planIDcardbeforeyoucanget
Priorauthorizationis: medicineorservices.
medicineorservices.

Reconstructive Theamountyoupayisbasedon Theamountyoupayisbasedon Nocoverageforcosmetic
Procedures wherethecoveredhealth wherethecoveredhealth procedures.
serviceisprovided. serviceisprovided.

Whatisareconstructive
procedure? Ispriorauthorization Ispriorauthorization
Aproceduretocorrectorimprove needed? needed?
apartofthebodybecauseof No Yes
birthdefects,accidents,injuries
ormedicalconditions. Priorauthorizationis:
Benefitsinclude: numberlistedonyourhealth
Breastreconstruction planIDcardbeforeyoucanget
medicineorservices.
followingamastectomyand

reconstructionofthenon
WhendoIneedtocall?
affectedbreasttoachieve
5businessdaysbeforea
symmetry
Dentalororthodonticservices scheduledprocedure
Assoonaspossiblefora
forcleftpalate
nonscheduledprocedure.
Viewtheglossaryfordefinitions. Ifyoudontgetprior
50%coinsurance

Rehabilitationand $20copaypervisit. 40%coinsurance,afteryou Limitsperyear:
HabilitativeServices Theannualdeductibledoesnot paythedeductible. 20visitsofphysicaltherapy.
apply. 20visitsofoccupational
OutpatientTherapy therapy.
Ispriorauthorization Ispriorauthorization 20visitsofspeechtherapy.
Whatarerehabilitation needed? needed? 20visitsofpulmonary
services?Healthcareservices No Yes
thathelpapersongetbacka therapy.
36visitsofcardiactherapy.
functionalskillthathasbeenlost Priorauthorizationis:
becauseofsicknessorinjury.
Example:Speechtherapyforan Gettingapprovalbycallingthe 30visitsofpostcochlear

adultwhohassufferedastroke. numberlistedonyourhealth implantauraltherapy.
planIDcardbeforeyoucanget 20visitsofcognitive
Whatarehabilitative medicineorservices. therapy.
services?Healthcareservices
thathelpapersonlearna WhendoIneedtocall? Ifmedicallynecessary,
functionalskillthatshouldbe 5businessdaysbefore additionalvisitsmaybe
presentbutisntbecauseof receiving: availablefor:
sicknessorinjury.Example: Physicaltherapy Physicaltherapy
Speechtherapyforanonverbal Occupationaltherapy Occupationaltherapy
childwithautism. Speechtherapy Speechtherapy

Wecover: Ifyoudontgetprior Therearenovisitlimitsfor
Physicaltherapy authorization,youpay: AutismSpectrumDisorder
Occupationaltherapy 50%coinsurance Services.
Pulmonarytherapy
Cardiactherapy Iftheserviceisprovidedina
Cochlearimplanthearing doctorsoffice,additionalco
therapy pays,deductibleorcoinsurance
mayapply.
Wealsocover:
Speechtherapytorestore
speech,language,voice,
communicationandauditory
processingafteraninjury,
stroke,cancer,congenital
anomaly,orautismspectrum
disorders.
Cognitivetherapywhen
medicallynecessaryaftera
braininjuryorcerebral
vascularaccident.

Outpatientservicesmustbegiven
byadoctororalicensed
therapist.


SmokingCessation Networkbenefitsarenot Outofnetworkbenefitsarenot Nocoveragefor:
covered. covered. Overthecounter(OTC)
Whatissmokingcessation? productsforsmoking
Servicestohelpyoustop cessation
smoking.


TemporomandibularJoint Theamountyoupayisbasedon Theamountyoupayisbasedon Nocoveragefor:
(TMJ)Services wherethecoveredhealth wherethecoveredhealth surfaceelectromyography
serviceisprovided. serviceisprovided. dopplerorvibration
analysis
WhatisTMJdisorder?
Ispriorauthorization Ispriorauthorization computerizedmandibular
Problemswiththejawjointthat
needed? needed? scanorjawtracking
mayincludepain,tenderjawsor
No Yes craniosacraltherapy
muscles,poppingorclickingin
dentalrestoration,
thejawjoint,earpain,headache
Priorauthorizationis: orthodonticsorocclusal
orlimitedjawmovement.
Gettingapprovalbycallingthe adjustment

Wecover:
Examsandtestingto medicineorservices.
diagnoseTMJdisorder
Oralappliances,splintsand
implants,andtriggerpoint WhendoIneedtocall?
injections 5businessdaysbeforea
Surgicaltreatmentif scheduledservice
allothertreatmentshave 24hoursbeforebeing
failed admittedforaninpatient
stay
Ifyoudontgetprior
50%coinsurance

TransplantationServices Theamountyoupayisbasedon Outofnetworkbenefitsarenot Transplantationservicesmust
wherethecoveredhealth available. bedoneatadesignatedfacility
Whatisanorgantransplant? serviceisprovided. exceptforcorneatransplants.
Thereplacementofadiseased
organwithahealthyorganfrom Ispriorauthorization Nocoveragefor:
adonorwitha needed? donatinganorgan
compatibletissuetype. Yes artificialoranimalorgans
experimental,investigational
Wecover: Priorauthorizationis: orunproventransplants
organandtissuetransplants Gettingapprovalbycallingthe
whenorderedbyadoctor numberlistedonyourhealth
removalofanorganfroma planIDcardbeforeyoucanget
donortoyou medicineorservices.

Thesemayinclude: WhendoIneedtocall?
bonemarrow Assoonasthepossibilityof
heart transplantarisesandbefore
lung yourpretransplant
kidney evaluation

pancreas
Ifyoudontgetprior
liver
smallbowel Allcharges
cornea

Formoreinformationabout
benefitsfortransplantservices
callthephonenumberonyour
healthplanIDcard.


Wigs Networkbenefitsarenot Outofnetworkbenefitsarenot Nocoverageforwigs.
covered. covered.
Whatisawig?Amanufactured
coveringofhairtowearonyour
head.

Viewtheglossaryfordefinitions

https://www.myuhc.com/member/ibaagMedicalDetailLayout.do?pageName=Special_Services&bookmark=Rehabilitation_Services_Outpatient_Thera 10/10

2007 - 2011 KA Generic HL Template

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5/19/2017 2007_2011KAGenericHLTemplate

Whatarechiropractic Ispriorauthorization Ispriorauthorization

Generalanesthesia Yes Yes Hasahealthissuethatrequires

Example:Speechtherapyforan Gettingapprovalbycallingthe 30visitsofpostcochlear

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