The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Emergency Admission Notification In order to avoid liability for charges that are not considered medically necessary, notification is recommended for unplanned admissions as a result of a medical emergency or injury as soon as reasonably possible or within 48 hours of the admission. For childbirth, notification is necessary if your stay will extend beyond 48 hours after a vaginal delivery or 96 hours after a Cesarean delivery (see the section “Inpatient Maternity Care” in this SPD). As mentioned previously under “Preadmission Notification”, verify with your provider if this is a service they will perform for you or if you will need to complete the notification. Ultimately, you are responsible for ensuring notification has been made to BCBS. See “Preadmission Notification Process” earlier in this section for information about how to provide notification to BCBS. If notification is not provided (whether recommended or required), and it’s determined at the point the claim is processed that services were not medically necessary, you are liable for all of the charges. Appealing a Preadmission Notification Decision If you disagree with a BCBS’ preadmission notification determination, you can seek additional review of that claim by following the procedure described under “Request for Review of Adverse Benefit Determinations” in the “Internal ERISA Claims Procedures” section in this SPD. Prior Authorization* Prior to receiving certain services, it is recommended that you contact BCBS for prior authorization to make sure the services are medically necessary before you or a covered dependent receives them. Verify with your provider if this is a service they will perform for you or if you will need to complete the prior authorization request. When you request prior authorization, BCBS will determine whether the services are medically necessary, appropriate, and eligible under the terms of your contract. If the services are determined to be cosmetic or otherwise not medically necessary, the services would not be covered and will be your responsibility. The services for which a prior authorization is recommended are: • Cosmetic versus medically necessary procedures - including, but not limited to: brow ptosis repair; excision of redundant skin (including panniculectomy); reduction mammoplasty; rhinoplasty; scar excision/revision; otoplasty; mastopexy • Coverage of routine care related to cancer clinical trials • Dental and oral surgery including, but not limited to: services that are accident-related for the treatment of injury to sound and healthy natural teeth; temporomandibular joint (TMJ) surgical procedures; and orthognathic surgery • Drugs - including, but not limited to: growth hormones; intravenous immunoglobulin (IVIG); oral fentanyl; subcutaneous immunoglobulin; rituximab for off-label usage; NPlate; Promacta; Tysabri; Cinryze; intravitrel implants; insulin-like growth factors; chelation therapy; botulinum toxin injections for off-label usage • Durable Medical Equipment (DME), prosthetics and supplies including, but not limited to: unlisted DME codes over $1,000; functional neuromuscular electrical stimulation; manual and motorized wheelchairs and scooters; respiratory oscillatory devices; heavy duty and enclosed hospital beds; pressure reducing support surfaces (group 2 and 3); wound healing treatment; implantable hearing devices or prosthetics; continuous glucose monitors; amino acid-based elemental formula; bone growth stimulators; communication assist devices; microprocessor controlled prosthetics 52
Retiree Health Care SPD Effective January 1, 2012 • Genetic testing including, but not limited to hereditary breast cancer and/or ovarian cancer • Home health care • Home infusion care involving drugs for which prior authorization is required • Hospice care • Humanitarian use devices (defined as devices that are intended to benefit patients by treating or diagnosing disease or condition that affects fewer than 4,000 individuals in the United States per year, classified under the FDA Humanitarian Device Exemption) • Imaging services including, but not limited to: Breast Magnetic Resonance Imaging (MRI); CT colonography (virtual colonoscopy) • Infertility treatment • Physical and occupational therapy (visits beyond the Programs’s annual 50 visit combined maximum) • Speech therapy (visits beyond the Program’s annual 25 visit maximum) • Surgical procedures including, but not limited to: bariatric surgery; hyperhidrosis surgery; spinal cord stimulators; subtalar arthroereisis for treatment of foot disorders; surgical treatment of obstructive sleep apnea and upper airway resistance syndrome; vagus nerve stimulation (for all conditions); spinal fusion; pelvic floor stimulation; ventricular assist devices • Transplants, except kidney and cornea This list may not be exhaustive and BCBS reserves the rights to revise, update, and/or add to this list at anytime without notice. The current list is available by calling BCBS Customer Service. * Final payment of benefits is based on the coverage you have on the day services are received, whether lifetime benefit maximums have been exceeded, and whether the service authorized is the service billed. Any decision to undergo treatment rests with the patient, subscriber, and the provider. If you want to verify whether a service is covered, you must call BCBS. Prior Authorization Request Process In order to avoid liability for charges that are not considered medically necessary, a prior authorization is required. While a Non-Notification Penalty will not apply if you fail to do so, should you not request prior authorization, and it’s determined at the point the claim is processed that services were not medically necessary, you are liable for all of the charges. Prior authorization requests should be submitted to BCBS at least 10 working days before the service is performed. You may submit your request by phone; the number to call is on the back of your BCBS ID card. If additional visits for occupational, physical and speech therapy will be needed beyond the Program’s annual visit maximum, you need to contact BCBS prior to the 51 st visit for occupational or physical therapy and prior to the 26 th visit for speech therapy. If the services are considered medically necessary, additional visits will be covered until either the condition resolves or the end of the plan year – whichever comes first. If the services are determined to not be medically necessary, the services would not be covered once the Program’s annual visit maximum has been reached and would be your responsibility. 53
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The eligibility and enrollment rules for the U

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