CURRY COLLEGE - University Health Plans

Summary of Benefits Chart (continued)
Additional Services and Discounts (continued)
Special Medical Special Medical Formula Expense
Formula Benefits are payable for newly born
Expense Benefits infants and adoptive children for those
special medical formulas. These formulas
must be approved by the Commissioner
of the Department of Public Health,
must be prescribed by a physician and
must be medically necessary for the
treatment of phenylketonuria, maple
syrup urine disease, propionic acidemia,
methylmalonic acidemia, or medically
necessary to protect the unborn fetuses
of pregnant women with PKU, and
screening for lead poisoning.
Non-
Presecription
Enteral Formula
Expense Benefits
Non Prescription Enteral Formula
Expense Benefits are payable for
nonprescription enteral formulas for
which a physician has issued a written
order. Such formulas must be medically
necessary for the treatment of
malabsorption caused by Crohn's disease,
ulcerative colitis, gastroesophageal reflux,
gastrointestinal motility, chronic intestinal
pseudoobstruction, and inherited diseases
of amino acids and organic acids.
Covered expenses for inherited diseases
of amino acids and organic acids shall
include food products modified to be low
protein in an amount not to exceed
$ 2,500 annually for any covered person.
21.