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

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Preventive Care The PPO/DRP pays benefits for the following types of preventive care services: Routine immunizations—including influenza and pneumococcal Routine gynecological exams and pap smears —limited to one per calendar year Routine mammograms—one mammogram per year Routine physical exams—limited to one per calendar year Routine laboratory tests and x-rays—including chemistry profile, CBC and lipid profile Routine prostate exams and prostate specific antigen (PSA) tests—limited to one per year Routine sigmoidoscopy and colonoscopy— limited to one per year Well child care—limited to six exams in the first year, three exams in the second year and one exam per year age 3 to 16, including immunizations, and Bone density scan. Note: The deductible does not apply to these services. To the extent services are considered “Preventive Care Services” they must be provided without any cost sharing requirements according to federal law. No deductible, copayments or coinsurance will apply to such service when provided by a participating provider. 26 Second Surgical Opinion The PPO/DRP will pay benefits toward the cost of a second surgical opinion by a board certified specialist who is not associated with the physician who provided the first opinion. (A third opinion is eligible in cases where the second opinion disagrees with the first.) Skilled Nursing Facility Care The PPO/DRP pays benefits for room, board, general nursing and ancillary services (such as drugs, surgical dressings or supplies) in a skilled nursing facility. Services will be covered at the inpatient hospital level after you have met the deductible. Services received in an uncertified skilled nursing facility are not covered. Special Equipment and Supplies Covered medically necessary special equipment and supplies include: Casts Splints Braces Trusses Colostomy and ileostomy bags and supplies required for their use Catheters Crutches Electronic pacemakers Surgical and orthopedic appliances Oxygen, and Initial pair of eyeglasses or contact lenses due to cataract surgery.
Other Covered Services Besides the services detailed above, the PPO/DRP covers the following types of services, supplies and treatments: Acupuncture to induce surgical anesthesia or for therapeutic purposes Chemotherapy Cosmetic surgery (limited to surgery to repair congenital defects, surgery needed because of accidental injury, and surgery to correct a condition resulting from infection, tumor or disease) Dental services required as a result of an accidental injury to the jaws, sound natural teeth, mouth or face (injuries due to chewing and biting are not covered) Oral surgery services required to: – remove full bony impacted teeth, excise tumors or to remove cysts of the jaws, cheeks, lips, tongue, or roof or floor of the mouth – correct accidental injuries of the jaw, cheeks, lips, tongue, or roof or floor of the mouth, or – excise exostoses of the jaws and hard palate (provided this procedure is not done in preparation for dentures or other prostheses) – treatment of fractures or facial bones, external incision and drainage of cellulites – incision of accessory sinuses, salivary glands or ducts, or – reduction of dislocation of jaw Note: Inpatient facility charges for oral surgery or dental treatment that ordinarily could be performed in the provider’s office will be covered only if the patient has a concurrent hazardous medical condition that prohibits treatment in an outpatient setting. 27 Treatment of temporomandibular joint (TMJ) syndrome and related care. Drugs and medicines when provided in the following manner: – covered injectables administered to you or your covered dependent while a patient at a physician’s office, or – drugs and medicines taken by or administered to you or your covered dependent while a patient in a hospital or other covered facility (Other retail prescriptions and mail order medications are covered under the plan’s prescription drug benefits—see Prescription Benefits, page 29). Medical supplies—excluding first aid supplies Orthotic devices and appliances—including initial purchase, fitting and repair (To be covered, the Claims Administrator must agree with the physician’s recommendation that such devices are medically necessary. Orthopedic shoes are not covered unless they are an integral part of a leg brace and included in the orthotist’s charge.) Patient education—including diabetic education and ostomy care Podiatry services performed by a physician or podiatrist Prosthetic devices to replace all or part of an absent body organ or the function of a permanently inoperative or malfunctioning organ, including charges for repair or medically necessary replacement (This does not include dental devices.) Therapy, including: – occupational, physical and speech therapy— including services for treatment of a congenital condition (limited to a combined maximum of 60 visits per year) – radiation therapy – chemotherapy Orthotics—provided they are custom fitted or custom-made braces, splints, casts used to support, align, prevent or correct deformities or to improve the function of movable parts of the body.
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 and 24: The PPO/DRP pays benefits if hospic
Page 25: Benefits for Newborns When you or a
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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