The eligibility and enrollment rules for the U

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.
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