PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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Benefits are available to both the recipient and donor of a covered transplant as follows: If both the donor and the recipient have coverage—Each person will have their benefits paid by their own program. If you or your covered dependent is the recipient, and the donor does not have coverage from any other source—The benefits described in this summary will be provided for both you and the donor. Payments made for the donor will be charged against the benefits you or your dependent receives. If you or your covered dependent is the donor, and coverage for the recipient is not available from any other source—The benefits described in this summary will be provided for you or your dependent. The recipient will not receive benefits under this plan. Benefits are not paid for: Investigational drugs, or Travel time and related expenses required by a physician or other provider. Infertility Treatment Benefits for covered services related to the treatment of infertility are paid the same as for any other condition, up to a lifetime maximum of $50,000. Infertility refers to the inability to conceive a child after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy. Covered services include: In vitro fertilization Uterine embryo lavage Embryo transfer Artificial insemination Gamete intrafallopian transfer (GIFT) Zygote intrafallopian tube transfer (ZIFT), and Low tubal ovum transfer. 24 Benefits are not paid for: Services rendered to a surrogate mother for purposes of childbirth Expenses incurred for cryo-preservation and storage of sperm, eggs and embryos, and Non-medical costs of an egg or sperm donor. Maternity Care The PPO/DRP covers the cost of pregnancyrelated services for you, your dependent spouse or your dependent female children on the same basis as any covered illness. The services must be received while you, your spouse or your dependent female children are covered under the PPO/DRP. Services provided in a birthing facility are eligible as long as the physician is acting within the scope of his or her license and the birthing facility meets all requirements. Midwife delivery services are eligible as long as the state in which they are performed legally recognizes midwife delivery, and the midwife is licensed at the time of delivery.
Benefits for Newborns When you or a covered dependent have a baby, the cost of routine nursery services for the newborn will be covered as part of the mother’s claim (whether the mother has single or family coverage). If the newborn is sick and requires more than routine nursery care, those additional expenses— as well as any expenses incurred for services provided to the newborn after the mother has been released from the hospital—will not be eligible for benefits unless the newborn is enrolled for coverage under the PPO/DRP within 90 days of his or her birth. Newborns’ and Mothers’ Health Protection Act The PPO/DRP intends to comply with the provisions of the Newborns’ and Mothers’ Health Protection Act. If you, a covered spouse or a dependent female child is having a baby, your PPO/DRP coverage generally may not, under this federal law, restrict benefits for any hospital stay in connection with childbirth to less than: 48 hours—following a normal vaginal delivery, or 96 hours—following a cesarean section. Note: This law does not prohibit the mother’s provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable. Lengths of stay that are expected to fall within these time periods do not have to be preauthorized by your medical coverage. That means you or your provider will not have to call a coverage representative before you or your covered spouse is admitted for childbirth. However, the additional days of a hospital stay that exceeds these timeframes must be preauthorized to ensure maximum benefits. 25 In addition, if the mother and the attending physician agree, the mother or newborn may be discharged earlier than 48 hours (or 96 hours, if applicable). Morbid Obesity Services in connection with bariatric surgery for morbid obesity will be covered provided these services have been pre-approved. Bariatric surgery includes—but is not limited to—gastric bypass and lap banding. Weight loss programs, dietary meals, nutritional supplements and over-the-counter dietary aids are not covered. Physician Services The PPO/DRP pays benefits for services provided by a physician who is duly licensed to practice medicine. These services include: Office visits, inpatient visits and home visits Surgical treatment (including surgical assistance, if required based on patient’s condition and if a hospital intern or resident is not available to provide assistance) Administering anesthesia Consultations while you are confined in a hospital or skilled nursing facility, unless the consultation: – is not requested by your attending physician – does not include another physician’s advice – is done because of hospital regulations, or – is provided by a physician performing any type of surgery during the same admission Radiologist or pathologist services for interpretation of x-rays and laboratory tests necessary for diagnosis and treatment, including radiation therapy and chemotherapy), and Allergy testing.
Page 1 and 2: PPO/DRP Medical Plan
Page 3 and 4: PPO/DRP Medical Plan If you are an
Page 5 and 6: You also may be invited to particip
Page 7 and 8: Services In-Network Out-of-Network
Page 9 and 10: Type of Services In-Network Out-of-
Page 11 and 12: Incapacitated Dependents A child wi
Page 13 and 14: You may be able to enroll yourself
Page 15 and 16: PPO/DRP Benefits The PPO/DRP covera
Page 17 and 18: Medically Necessary Services A proc
Page 19 and 20: You must call to schedule a non-urg
Page 21 and 22: Chiropractic Care The Plan will pay
Page 23: The PPO/DRP pays benefits if hospic
Page 27 and 28: Other Covered Services Besides the
Page 29 and 30: Weight reduction or treatment of ob
Page 31 and 32: Making a Claim Filing a Claim Any c
Page 33 and 34: However, if a claim is submitted th
Page 35 and 36: The consulting health care professi
Page 37 and 38: If the claimant’s request is comp
Page 39 and 40: Other Plan Information When Medical
Page 41 and 42: Reimbursement/Subrogation You and y
Page 43 and 44: Assignment of Benefits A Qualified
Page 45 and 46: Your Benefits If you elect to conti

PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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