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

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– cardiac therapy—if you are recovering from a myocardial infarction or a coronary bypass procedure or have been diagnosed with coronary disease, angina pectoris, valvular heart disease, exercise-triggered cardiac arrhythmia, or other conditions determined by the Claims Administrator, and these services are provided within six months of your hospital admission (limited to 36 visits) – dialysis treatment including hemodialysis and peritoneal dialysis – respiratory therapy, and Surgery for treatment of morbid obesity, if approved by the Claims Administrator. Women’s Health and Cancer Rights Act of 1998 The PPO/DRP intends to comply with the provisions of the Women’s Health and Cancer Rights Act of 1998. Your Advocate-sponsored medical coverage provides benefits for mastectomy-related services and the complications resulting from a mastectomy (including lymphedema). These benefits include reconstruction and surgery to achieve breast symmetry and prostheses. Normal copayments, deductibles and coinsurance under your PPO/DRP coverage (described on pages 6-9) may apply. Services That Are Not Covered This section describes general services that are not covered under your PPO/DRP coverage. Information about specific non-covered services is listed under each section. The PPO/DRP does not pay benefits for services that are not medically necessary. Note: The preceding section—Covered Services— includes references to certain services that are not covered. These non-covered services and the ones listed in this section are examples of non-covered services, but do not constitute an all-inclusive list. Please contact the claims administrator if you have questions. 28 Charges for more than one item of equipment for the same or similar purpose are not covered under the PPO/DRP. Benefits also will not be provided for services, supplies or treatments that are not specifically provided for in the plan document, are primarily educational in nature (unless specified) or that are related to or for: Reversal of sterilization procedures Surrogate mother embryo implantation Transexualism, gender dysphoria or sexual reassignment or change Sexual dysfunction—unless related to organic illness Hospital admissions on a Friday, Saturday or Sunday—unless the admission is due to an emergency situation or surgery is scheduled within 24 hours Hospital room and board when only diagnostic tests are performed Marital counseling Treatment of injury or disease of the teeth, oral surgery, treatment of gums or structures, or removal or replacement of teeth or dental implants—unless specified Eye refractions, orthoptics, eyeglasses, or contact lenses—unless specified Any eye surgery solely for the purpose of correcting refractive defects of the eye Metabolic or peripheral-vascular illness, routine, palliative or cosmetic foot care— except as medically necessary (e.g., routine foot care for a person diagnosed with diabetes) Personal comfort or beautification items— whether or not recommended by a physician Non-prescription drugs such as vitamins, cosmetic dietary aids and nutritional supplements Orthopedic shoes (except when they are an integral part of a leg brace and their cost is included in the orthotist’s charges) or shoe inserts Cosmetic surgery—unless otherwise specified Charges incurred as a result of or in connection with any procedure or treatment excluded by your plan that has resulted in medical complications
Weight reduction or treatment of obesity as specifically provided and approved by the Claims Administrator Smoking cessation programs or treatment of nicotine addiction except as provided through Healthe You. Examinations to determine hearing loss, or for the fitting, purchase, repair or replacement of hearing aids An employment physical, insurance physical or sports physical Services, supplies or treatments that are experimental/investigational Custodial care, domiciliary care or rest cures Travel or accommodations, whether or not recommended by a physician—unless otherwise specified Wigs, artificial hairpieces, artificial hair transplants or any drug used to stimulate hair growth—does not apply when baldness is the result of burns, chemotherapy, radiation therapy or surgery (purchase of wig or artificial hairpiece is limited to one per lifetime under these circumstances) Hypnosis Copayments or deductibles under Advocate’s Prescription Benefits Program Professional services billed by a physician, R.N., L.P.N. or L.V.N. who is an employee of a hospital or any other facility, and who is paid by the hospital or facility for the service provided Environmental change, including hospital or physician charges connected with prescribing an environmental change Room and board in a facility for days on which you or your covered dependent is permitted to leave Charges for missed appointments, copies of medical records and other clerical services, or Charges in connection with any illness or injury arising out of or in the course of any employment intended for wage or profit, including self-employment. 29 Prescription Benefits If you choose the PPO/DRP coverage option, you will be covered automatically under the Advocate Prescription Benefits Program, which is administered by CVS/Caremark. It provides benefits for prescription medicines purchased at retail pharmacies in the Caremark network of participating pharmacies (including major chains such as Osco, Walgreens, Dominicks or Target) or through Caremark’s mail order program. After you pay a per-prescription copayment, this program will pay the full cost of your prescription medicines. Important! If a generic equivalent is available and you have the prescription filled with a nonpreferred brand drug, you will pay—in addition to the copayment—the difference between the cost of the non-preferred brand drug and the generic drug Certain limitations and exclusions apply under the Prescription Benefits Program, and some medications—such as certain amphetamines, anabolic steroids, cosmetic hair removal products—are excluded from this coverage. More detailed information about this program, including the copayment limits that apply to certain drugs, value generics, specialty drugs exclusions, the prior authorization requirement and the complete Performance Drug Listing (PDL) of preferred brand name drugs, is available online at www.advocatebenefits.com (click on Benefits Information > Prescription Benefits).
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 and 26: Benefits for Newborns When you or a
Page 27: Other Covered Services Besides the
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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