Blue Choice HMO Benefits - Harford County Public Schools

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J. Any prescription drugs obtained and self-administered by the Member for outpatient use unless the prescription drug is specifically covered under this Contract. Medications that can be self-administered or do not medically require administration by or under the direction of a physician are not covered even though they may be dispensed or administered in a physician office or provider facility. Benefits for prescription drugs may be available through an Attachment to the Contract. K. All non-prescription drugs, medications, biologicals, and Over-the-Counter disposable supplies, routinely obtained and self-administered by the Member, except as stated in the Description of Covered Services. L. Any procedure or treatment designed to alter an individual’s physical characteristics to those of the opposite sex. M. Services to reverse voluntary, surgically induced infertility, such as a reversal of sterilization. N. Fees or charges relating to fitness programs, weight loss or weight control programs, physical conditioning, exercise programs, physical conditioning, use of passive or patient-activated exercise equipment. O. Treatment for weight reduction and obesity except for the surgical treatment of Morbid Obesity as described in the Description of Covered Services. P. Medical or surgical treatment of myopia or hyperopia. Coverage is not provided for radial keratotomy and any other forms of refractive keratoplasty, or any complications. Q. Services furnished as a result of a referral prohibited by law. R. Services solely required or sought on the basis of a court order or as a condition of parole or probation unless authorized or approved by CareFirst BlueChoice. S. Health education classes and self-help programs, other than birthing classes, smoking cessation classes, or for the treatment of diabetes. T. Acupuncture services except when approved or authorized by CareFirst BlueChoice when used for anesthesia. U. Any service related to recreational activities. This includes, but is not limited to, sports, games, equestrian, and athletic training, even though such services may be deemed to have therapeutic value. V. Any service received at no charge to the Member in any federal Hospital or facility, or through any federal, state or local governmental agency or department, not including Medicaid. This exclusion does not apply to care received in a Veteran’s Hospital or facility unless that care is rendered for a condition that is a result of the Member’s military service. W. Private duty nursing. X. Non-medical, Health Care Provider services, including, but not limited to: 1. Telephone consultations, charges for failure to keep a scheduled visit, completion of forms, copying charges or other administrative services provided by the Health Care Provider or his/her staff. MD/GHMSI/CFMI BC (R. 10/10) CareFirst BlueChoice Harford County Public Schools 42 7/1/2011
2. Administrative fees charged by a Health Care Provider to a Member to retain the Health Care Provider services, e.g., “concierge fees” or boutique medical practice membership fees. Benefits under this Contract are limited to Covered Services rendered to a Member by a Health Care Provider. Y. Educational therapies intended to improve academic performance. Z. Vocational rehabilitation and employment counseling. AA. BB. CC. DD. EE. FF. GG. HH. Services performed or prescribed by or under the direction of a person who is acting beyond his/her scope of practice. Services performed or prescribed by or under the direction of a person who is not a Health Care Provider. Oral surgery, dentistry or dental process unless otherwise stated. Treatment of temporomandibular joint disorders unless otherwise stated. Habilitative Services for a Member under 21 years of age. Rehabilitative Services delivered through early intervention and school services. Services related to human reproduction other than specifically described in this Contract including, but not limited to maternity services for surrogate motherhood or surrogate uterine insemination, unless the surrogate mother is a Member. Work Hardening Programs. Work Hardening Programs are highly specialized rehabilitation programs designed to simulate workplace activities and surroundings in a monitored environment with the goal of conditioning the participant for a return to work. 12.2 Infertility Services. Coverage will not be provided when: A. The Member or spouse has undergone elective sterilization with or without reversal. B. Any surrogate or gestational carrier is used. C. The service involves the use of donor egg(s), donor sperm or donor embryo(s). D. The service involves the participation of a common law spouse, except in states that recognize the legality of those relationships. Coverage will not be provided for: E. Cryopreservation, storage, and or thawing of sperm, egg(s), or embryo(s). F. Any charges related in any way to the acquisition, maintenance, storage, examination, testing, sterilization or preservation of donor eggs and/or donor sperm. 12.3 Organ and Tissue Transplants. Coverage is not provided for: A. Non-human organs and their implantation. This exclusion will not be used to deny Medically Necessary, non-experimental skin grafts that are covered under the Contract. MD/GHMSI/CFMI BC (R. 10/10) CareFirst BlueChoice Harford County Public Schools 43 7/1/2011
Page 1 and 2: ATTACHMENT A DESCRIPTION OF COVERED
Page 3 and 4: . The amount negotiated with contra
Page 5 and 6: C. CareFirst BlueChoice may require
Page 7 and 8: F. Obstetric and Gynecological Care
Page 9 and 10: 2.2 Outpatient Surgical Care. Benef
Page 11 and 12: Multiple Project Assurance Contract
Page 13 and 14: 2.8 Morbid Obesity. A. Benefits are
Page 15 and 16: E. Services as a result of accident
Page 17 and 18: SECTION 3 INPATIENT HOSPITAL SERVIC
Page 19 and 20: 2. Ninety-six (96) hours for both t
Page 21 and 22: D. The Member requires Skilled Nurs
Page 23 and 24: G. The need for home health service
Page 25 and 26: K. Bereavement Services will be pro
Page 27 and 28: health or substance abuse treatment
Page 29 and 30: 2. Assessment and stabilization ser
Page 31 and 32: B. Hearing Aid means a device that
Page 33 and 34: E. Orthotic Devices, Prosthetic Dev
Page 35 and 36: SECTION 10 VISION CARE SERVICES Thi
Page 37 and 38: SECTION 11 REFERRALS 11.1 Referral
Page 39 and 40: 11.4 Conditions for a Referral to a
Page 41: SECTION 12 EXCLUSIONS AND LIMITATIO
Page 45 and 46: H. Custodial Care, domestic or hous
Page 47 and 48: SECTION 13 SCHEDULE OF BENEFITS Car
Page 49 and 50: SERVICE LIMIT ON BENEFITS SUBJECT T
Page 51 and 52: SERVICE LIMIT ON BENEFITS SUBJECT T
Page 53 and 54: SECTION 7 - MENTAL HEALTH AND SUBST

Blue Choice HMO Benefits - Harford County Public Schools

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