Previous Policy

Acupuncture

80% Network and Non-Network The Acupuncture Benefit Is Not Available Under Retiree Coverage For Those Who Are Eligible For Medicare

Benefits are provided for acupuncture when provided by a licensed provider with a 24 combined visit calendar year maximum for acupuncture, massage therapy, and chiropractic care. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or $4,000 out-of-pocket maximum. Services and supplies:

• New or established patient examination per condition.
• Acupuncture only.

Benefits are not provided for:

1. More than one visit per day.
2. Manual or massage therapy.
3. Heat therapy, cupping, therapeutic exercise, or neuromuscular reeducation.
4. Any other service or supply such as an unlisted therapeutic procedure, kinetic activities, electromagnetic, or infrared therapy.

Previous Policy

Alternative Care

80% Network and Non-Network

Alternative care may be covered in lieu of regular plan benefits for dates of service beginning September 1, 2021 if certain conditions are met. Alternative care must be approved in writing, medically necessary and must meet accepted medical community standards and result in no additional cost to the plan. For example, alternative care could be coverage for home care or a skilled nursing facility in lieu of hospitalization.

Previous Policy

Ambulance

90% Network and Non-Network

Benefits are provided for services and supplies for licensed ambulance transportation to the nearest hospital or Medicare-approved skilled nursing facility which has the appropriate facilities to treat the patient’s condition when the patient requires immediate medical intervention as a result of a severe, life threatening or potentially disabling condition, and only if any other means of transportation would seriously endanger the patient’s life. Licensed ambulance transportation is also provided in the following situations:

• Ambulance service is from one hospital to another, including return, but only in situations where evidence clearly establishes that the institution to which the patient is being transferred is the nearest one having appropriate facilities, equipment or staff physicians to treat the patient’s condition or to obtain medically necessary diagnostic or therapeutic services not available at the patient’s hospital or skilled nursing facility.
• Licensed air ambulance but only to the nearest medical facility that can provide the needed medical treatment. Air ambulance services are covered only when the point of pickup is inaccessible by land, or great distances or other obstacles are involved in getting the patient to the nearest appropriate facility, and speedy admission is essential. If it is determined that a ground ambulance would have sufficed, this plan pays only the amount it would have paid for a ground ambulance.

If the patient is transported beyond the nearest appropriate facility, benefits are prorated accordingly.

Benefits are not provided for:

1. Ambulance use to or from a place of residence and a physician’s office.
2. Ambulance use from a hospital back to a place of residence.
3. Ambulance service to or from any facility for the effective treatment or assessment of chemical dependency.
4. Cabulance services or any other commercial transportation.
5. Transportation for the patient’s or provider’s convenience.

Previous Policy

Anesthesia

90% Network and 80% Non-Network

Benefits are provided for the services of an anesthesiologist required for a covered surgery. If you receive services from a non-network provider at a network facility, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums.

Benefits are not provided for:

1. The patient’s or physician’s convenience or for fear anxiety states.
2. General anesthesia or IV sedation for surgical procedures commonly and primarily performed in a clinic or physician’s office.
3. General anesthesia or IV sedation for dental procedures except as provided and paid for under Dental Benefits as administered by Delta Dental of Washington.

Previous Policy

Autism Spectrum Disorder/Pervasive Developmental Disorder

90% Network and 80% Non-Network

The plan provides coverage for medically necessary Applied Behavioral Analysis (ABA)–based therapy. Treating providers must be certified under applicable state law to provide ABA therapy.

Previous Policy

Bariatric Surgery

90% Network Only Services and Supplies Must Be Received From A Network Provider The Bariatric Surgery Benefit Is Not Available Under Retiree Coverage

Surgical procedures for morbid obesity including Roux-en-Y gastric bypass (RYGB), FDA-approved adjustable gastric banding, or sleeve gastrectomy are covered at network providers only. All procedures must be preauthorized. To initiate the preauthorization process, your physician must call the provider number on the back of the medical plan ID card.

Previous Policy

Behavioral Health Services

90% Network and 80% Non-Network Services and Supplies Must Be Preauthorized Unless the Patient Is A Medicare-Eligible Retiree

Behavioral health services refers to the category of services including mental health, substance use disorder and other behavioral health services. These services include inpatient, residential treatment facility, partial hospitalization, intensive outpatient and outpatient treatment. Office visit copayments apply except for the treatment of substance use.

Services must be received from a licensed provider. Providers and licenses can vary by state but commonly include, psychiatrists, psychiatric nurse practitioners, psychologists, clinical social workers, marriage and family therapist, mental health counselors, and chemical dependency counselors.

The facility must be licensed in the state where it operates and all charges are for items provided within the scope of that license and has accreditation under the Joint Commission on Accreditation of Hospitals (JCAHO) or Commission on Accreditation of Rehabilitation Facilities (CARF).

Previous Policy

Blood

90% Network and 80% Non-Network

Benefits are provided for services and supplies associated with the administration of blood and blood plasma. Extraction and storage of autologous blood and blood derivatives in advance of a covered scheduled surgery is also provided. Blood, packed blood cells, plasma, or any element of blood that can be replaced by a voluntary donor are not covered.

Previous Policy

Chiropractic Care

80% Network and Non-Network

Benefits are provided for chiropractic care by a licensed provider with a 24 combined visit calendar year maximum for chiropractic care, acupuncture and massage therapy. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or $4,000 out-of-pocket maximums. Services and supplies include:

• New or established patient examination.
• Initial plane x-ray of the spine.
• Spinal manipulations.

Other services may be covered under rehabilitative care or other plan benefit provisions.
Benefits are not provided for:

1. Manipulations of any parts of the body which are not articulations of the spine.
2. New or established patient examination in addition to spinal manipulations on the same day except when examination is required to assess a new episode of care and the patient has not been treated by the provider within the previous 90 days and is not undergoing any active treatment for that condition or diagnosis.
3. Treatment by machine including, but not limited to, vibrasonic therapy, ultrasound therapy, hydrotherapy.
4. More than one (1) spinal manipulation per day.

Previous Policy

Dental Accidents

90% Network and 80% Non-Network

Dental Accidents

Benefits are provided for services and supplies performed by a physician (MD or DO) or dentist (DDS or DMD) for the prompt repair of sound natural teeth (as defined in number one below) when damaged as a result of an injury. Covered services and supplies include only those dental procedures completed within 270 days following the date of the accident, and only if the individual remains eligible under this plan. Benefits are provided based on the maximum allowable fee.
The following limitations apply to this benefit:

1. Any tooth being repaired must have been a sound natural tooth, meaning whole or properly restored, without impairment or periodontal disease, and not in need of treatment for reasons other than the dental injury. Repair or replacement of existing crowns or prosthetic appliances will be covered under this benefit if satisfactory proof is submitted documenting that the need for repair or replacement is a direct result of the injury.
2. If crowns, dental implants, dentures, bridgework, or in-mouth appliances are installed as a result of an injury, the plan allows only the first denture or bridgework to replace lost teeth, the first crown or dental implant to repair each damaged tooth, or the in-mouth appliance that is installed as the first course of orthodontic treatment following the injury. A dental implant is considered acceptable treatment when clear clinical evidence shows a conventional fixed or removable prosthesis cannot provide clinically acceptable treatment. If dental implant treatment is elected when a conventional fixed or removable prosthesis provides acceptable clinical treatment, an allowance for the implant will be provided based on the cost of a conventional fixed or removable prosthesis as determined by this plan.

Other Dental Treatment

The plan covers medically necessary general anesthesia and hospitalization if such anesthesia services and related facility charges are medically necessary because the covered person:

• Is under the age of seven, or physically or developmentally disabled, with a dental condition that cannot be safely and effectively treated in a dental office; or
• Has a medical condition that the person’s physician determines would place the person at undue risk if the dental procedure were performed in a dental office. The procedure must be approved by the person’s physician.

Benefits are not provided for:

1. Services or supplies related to the removal, repair, replacement, restoration, or repositioning of teeth lost or damaged in the course of biting or chewing.
2. Procedures, appliances or restorations that are primarily for cosmetic purposes, including any direct or indirect complications thereof.
3. Services or supplies resulting from illness or disease, or that is in any way related to an illness or disease.
4. Any other dental treatment under medical benefits except as provided in this section.

Previous Policy

Diabetic Care

90% Network and 80% Non-Network

Benefits are provided for an approved diabetic training program prescribed by a physician, including education, training, meal planning (although not the cost of meals), and treatment and prevention of hyperglycemia or hypoglycemia. Coverage is also provided for diabetic supplies including injection aids and blood glucose monitors. If your physician prescribes a home blood glucose monitor, you may purchase the monitor from a pharmacist and submit the pharmacy receipt with the completed claim form to Carpenters Trusts. Home blood glucose monitors cannot be processed through the prescription drug programs.

If you are diabetic and not eligible for Medicare, you must purchase insulin, syringes, blood glucose testing strips, and lancets through one of the prescription drug programs – the Express Scripts Retail Pharmacy Program, Walgreens Exclusive Smart90® Program or Express Scripts By Mail. Prescriptive agents for controlling blood sugar levels must also be purchased through one of the prescription drug programs. If you purchase these items from a nonparticipating pharmacy or other diabetic supplier, you must pay full retail price and submit a Prescription Drug Reimbursement Form to Express Scripts. Express Scripts will reimburse you at 100 percent of the “average wholesale price” – the program’s discounted price – less the appropriate copayment.

Previous Policy

Diagnostic X-ray and Laboratory Services

90% Network and 80% Non-Network

Benefits are provided for radiology (x-ray), pathology, laboratory tests, and other imaging and diagnostic services ordered by a physician for the diagnosis of an illness or injury. All services must be related to a definitive set of symptoms, except as provided under Preventive Health Services.

Previous Policy

Durable Medical Equipment

90% Network and 80% Non-Network

Benefits are provided for durable medical equipment (DME) prescribed by a physician for use in the patient’s home including, but not limited to, crutches, wheelchairs, oxygen-related equipment, and standard hospital beds. To be covered, the equipment must meet certain criteria established by this plan including:

• The equipment must withstand repeated use.
• The only function of the equipment is for treatment of the medical condition or it contributes to the improvement of function related to the condition.
• The equipment is for the patient only.
• The equipment is appropriate for home use. A skilled nursing facility, rehabilitation facility or hospital is not considered the patient’s home.

Extensive maintenance based on the equipment manufacturer’s recommendations to be performed by authorized technicians is also covered.

If the rental or purchase is not preauthorized, the plan may deny the charge in part or whole. The fact that an item may serve a useful medical purpose does not ensure that benefits will be provided. The plan may also elect to provide benefits for a less costly alternative item.

Benefits are not provided for:

1. Equipment received or ordered when a plan benefit is not in effect or when the patient is not covered under this plan.
2. Rental in excess of a reasonable purchase price.
3. Personal convenience items such as, but not limited to, heating pads, enuresis (bed wetting) training equipment, whirlpool baths, bath aids, raised toilet seats, exercise equipment, muscle stimulators, weights, keyboard communication devices, adjustable beds, three-wheeled scooters, orthopedic chairs, customized car seats or strollers, feeding chairs, personal hygiene items, blood pressure devices, or deluxe items such as motorized equipment.
4. Freight, postage or delivery charges.
5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps, support railings, air conditioners, humidifiers, or air filter systems.
6. Equipment for which the primary purpose is preventing illness or injury; equipment primarily designed to assist a person caring for the patient; or equipment not useful in the absence of the patient’s condition.
7. Routine periodic servicing, such as testing, cleaning, regulation, and checking of the patient’s equipment.
8. Repair or replacement of equipment until five years have elapsed unless medical necessity is proven.
9. Batteries.

Previous Policy

Erectile Dysfunction

90% Network and 80% Non-Network

Benefits are provided for the treatment of organic erectile dysfunction if the patient has a history of one or more of the following:

• Prostate cancer.
• Severe spinal cord disease or injury.
• Insulin-dependent diabetes.
• Severe Peyronie’s disease.

Covered treatment includes vacuum erection devices, injection therapy, penile prosthesis, urethral pellets, and prescription medications (please see Prescription Drug Benefits).

Previous Policy

Habilitative Care

90% Network and 80% Non-Network

Habilitative care refers to health care services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical, speech and occupational therapy, and other services for individuals with disabilities in a variety of inpatient and/or outpatient settings.

Inpatient Care

Benefits are provided for a semiprivate room in a hospital with a rehabilitation department or a rehabilitation hospital. Inpatient admissions are covered for physical, speech, respiratory, and occupational therapy services and supplies, with a calendar year maximum of 15 inpatient days. If charges for more than 15 inpatient days are submitted, those charges will be denied. Inpatient care is only covered when services cannot be provided in a less intensive setting. The annual inpatient maximum applies to habilitative and rehabilitative services combined.

Outpatient Care

Benefits are provided with a calendar year maximum of 30 outpatient visits. visits. If, however, the ordering physician determines additional visits are medically necessary, a fully documented request can be made to the plan. Up to an additional 30 visits may be allowed (a total of 60 visits per calendar year) based on the information provided by the ordering physician to the plan. This benefit maximum applies to habilitative and rehabilitative services combined.

Benefits are not provided for:

1. Respite care, education services, chore services to assist with basic needs, social services, recreational care, residential treatment, vocational training or custodial services.
2. Self-correcting dysfunction such as hoarseness.
3. State-required medical assessments for specialized educational programs; or services or supplies required by law to be provided by any school system.
4. Feeding therapy.

These exclusions apply to inpatient and outpatient care.

Previous Policy

Hearing Aids

90% Network and 80% Non-Network The Hearing Aid Benefit Is Not Available Under Retiree Coverage

Benefits are provided for hearing aids prescribed by a physician or audiologist with a maximum of $1,000 per ear in any three consecutive year period. If the patient purchases a replacement hearing aid and is eligible for benefits (subject to the applicable exclusions shown below), the prescription requirement is waived. Covered services and supplies include:

• An otologic examination by a physician.
• An audiological examination and hearing evaluation by a certified or licensed audiologist including a follow-up consultation.
• The hearing aid (monaural or binaural) prescribed as a result of such examination, which includes ear mold(s), the hearing aid instrument, the initial batteries, cords and other necessary related equipment, a warranty, and follow-up consultation within thirty days following delivery of the hearing aid.

Benefits are not provided for:

1. Replacing a hearing aid or a hearing aid part for any reason more than once in a three-year period.
2. Hearing aids purchased or dispensed when the benefit is not in effect or when the patient is not covered under this plan.
3. Batteries or other equipment other than that obtained upon purchase of the hearing aid.
4. Charges for hearing aids that do not meet professionally accepted standards of practice, including charges for any such services or supplies that are experimental in nature.
5. A hearing aid which exceeds the specifications prescribed for correction of hearing loss.

Coverage Following Termination of Eligibility

When a hearing aid is prescribed and ordered prior to termination of coverage, benefits are available if the prescribed device is delivered and purchased within 60 days after termination of coverage. Benefits are based on the benefits in effect on the date coverage terminated.

Previous Policy

Home Health Care

100% Network and Non-Network Services and Supplies Must Be Precertified Unless the Patient Is a Medicare-Eligible Retiree

Benefits are provided for home health care services provided by an approved home health care agency and prescribed by a physician if inpatient care in a hospital or skilled nursing facility would otherwise be required. There is an annual maximum of 30 visits. The patient must be “homebound” meaning the patient cannot leave his or her home without a considerable and taxing effort and is unable to use public transportation without the assistance of another.
Benefits are limited to the following home health care services and supplies which must be provided by employees of, and billed by, an approved home health care agency:

• Nursing services provided by a registered nurse (RN) or licensed practical nurse (LPN).
• Physical therapy provided by a physical therapist.
• Speech therapy provided by a speech therapist.
• Occupational therapy provided by an occupational therapist.
• Respiratory therapy provided by a respiratory therapist.

Prescription drugs and medicines, infusion therapy and IV antibiotics, and durable medical equipment are covered under separate benefits.

Benefits are not provided for:

1. Custodial care; nonmedical self-help or related testing; vocational, educational, cognitive, or behavioral therapy; or exercise programs.
2. Home health aide services.
3. Services provided by volunteers, household members, family, or friends.
4. Food, clothing, housing, or transportation.
5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps or support railings.
6. Services or supplies not included in the written treatment plan or not otherwise specifically covered.
7. Homemaker or housekeeping services.

Previous Policy

Home Phototherapy

90% Network and 80% Non-Network

Benefits are provided for services and supplies prescribed by a physician for home phototherapy. This benefit is for newborn hyperbilirubinemia (jaundice) children only.

Previous Policy

Hospice Care

100% Network and Non-Network

Hospice care refers to palliative care (medical relief of pain and other symptoms) for patients who have been diagnosed as terminally ill and whose life expectancy has been determined to be six months or less. A “hospice program” is defined as a public agency or a private organization that is primarily engaged in providing the care and services described below and that makes these services available as needed, on a 24-hour basis. The hospice program provides care and services in a patient’s home and on a short-term inpatient basis. The hospice program can either be a Medicare-certified hospice agency or certified as a hospice care agency by the Washington State Department of Social and Health services or the equivalent department of another state. A provider that is certified for Medicare participation as a hospital, skilled nursing facility, or home health agency may be certified as a hospice.

Benefits are provided for the services and supplies of an approved hospice agency for a maximum of six months as described below.

Covered Charges for Services in the Patient’s Home

Home hospice care services are covered if the patient is ill enough for hospitalization. In addition, the patient must be “homebound” meaning the patient cannot leave the home without a considerable and taxing effort and is unable to use public transportation without the assistance of another. Benefits are limited to the following services which must be provided by employees of, and billed by, an approved hospice:

• Physician services.
• Nursing services by a registered nurse (RN) or licensed practical nurse (LPN).
• Physical therapy by a physical therapist.
• Speech therapy by a speech therapist.
• Occupational therapy by an occupational therapist.
• Respiratory therapy by a respiratory therapist.
• Medical social services by a licensed social worker (MSW) under the direction of a physician.
• Home health aide services by an aide who is under the supervision of a registered nurse are limited to the following: part-time or intermittent care including ambulation and exercise, personal care essential to achieve the medically desired result, assistance with medications, the reporting of changes in the patient’s condition and needs, and completion of appropriate records.
• Medical supplies dispensed by the hospice that would have been provided on an inpatient basis.
• Drugs and medicines dispensed by or through the hospice agency that are legally obtainable only with a physician’s written prescription or provided on an inpatient basis but only such drugs and medicines which are reasonable and necessary for palliation and management of terminal illness.
• Respite care meaning continuous care of the patient to provide temporary relief to family members or friends from the duties of caring for the patient.
• Nutritional guidance by a registered dietitian.

The following limits apply to hospice care received in the patient’s home:

1. Visits of one or more hours in which skilled care is required by a registered nurse (RN), licensed practical nurse (LPN), home health aide, licensed social worker (MSW), or a physical, speech or respiratory therapist are limited to a combined total of 60 visits.
2. Respite care in which no skilled care is required is limited to a combined total of 120 hours per three-month period.

Covered Charges for Inpatient Hospice Services

When a patient is confined as an inpatient in an approved hospice facility, the same benefits that are available in the patient’s home are available to the patient on an inpatient basis. These services must be provided by employees of, and billed by, the approved hospice agency. This inpatient hospice benefit is limited to 14 days during the six-month benefit period.
Benefits are not provided for (in the patient’s home or inpatient hospice services):

1. Services for spiritual counseling.
2. Services to other family members.
3. Services provided by volunteers, household members, family, or friends.
4. Food, clothing, housing, or transportation.
5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps or support railings.
6. Homemaker or housekeeping services.
7. Financial or legal counseling services.
8. Custodial or maintenance care, except that benefits are provided for palliative care to a terminally ill patient subject to the limits stated.
9. Services or supplies not included in the written treatment plan or not specifically set forth as a covered benefit.

If, while receiving hospice care, a patient requires treatment for a condition not related to the terminal illness, normal plan benefits apply.

Previous Policy

Hospital Services and Supplies

90% Network and 80% Non-Network

Inpatient Hospital

Benefits are provided for the following services and supplies:

• A semiprivate room and hospital services and supplies to treat an illness or injury.
• Intensive and coronary care units.
• Operating rooms and equipment.
• Nursing services (other than the services of a private-duty nurse or attendant).
• Diagnostic or therapeutic items or services that are ordinarily furnished by the hospital for the care and treatment of the patient.
• Anesthesia including administration and materials.
• Drugs, biologicals, supplies, appliances, and equipment for use in the hospital that are ordinarily furnished by the hospital for the care and treatment of the patient.

Benefits are not provided for:

1. A bed or room set aside for a patient while the patient is in a special care unit.
2. Fees for a hospital, ambulatory surgical center or other surgical facility for surgical services commonly and primarily performed in a clinic or physician’s office.

Outpatient Hospital

Benefits are provided for:

• Services and supplies otherwise provided on an inpatient hospital basis.
• Facility fees for outpatient surgery, a same-day surgical center or an ambulatory surgical center.
• Treatment including x-ray, radium therapy and other radioactive substances, chemotherapy, and laboratory and diagnostic radiology and imaging.
• Care in a hospital emergency room. There is a $50 copayment for each visit to the emergency room. The $50 copayment is waived if the patient is admitted as an inpatient directly following treatment in the emergency room.

Benefits are not provided for fees for a hospital, ambulatory surgical center or other surgical facility for surgical services commonly and primarily performed in a clinic or physician’s office.

Previous Policy

Infusion Therapy

90% Network and 80% Non-Network

Benefits are provided for services and supplies for infusion therapy including, but not limited to, total nutritional therapy administered intravenously and IV antibiotics. The plan reserves the right to select a less costly supplier to provide the services and supplies.

Previous Policy

Kidney Dialysis

90% Network and 80% Non-Network

Benefits are provided for kidney dialysis performed in a hospital, an approved kidney dialysis treatment center or in a patient's home when it is repetitive and for chronic, irreversible kidney disease. Benefits may also be provided for the rental or purchase of home kidney dialysis equipment.

Previous Policy

Massage Therapy

80% Network and Non-Network The Massage Therapy Benefit Is Not Available Under Retiree Coverage For Those Who Are Eligible For Medicare

Benefits are provided for massage therapy when provided by a licensed massage therapist with a 24 combined visit calendar year maximum for massage therapy, chiropractic care and acupuncture. These services always require 20 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or $4,000 out-of-pocket maximum. Services and supplies include:

• Massage therapy only.

Benefits are not provided for:

1. More than one massage per day.
2. Lubricants (for example oils, lotions, emollients).
3. Any other service or supply.

Previous Policy

Medical Supplies

90% Network and 80% Non-Network

Benefits are provided for the following items prescribed by a physician if the patient has an immediate medical need: sterile surgical dressings; casts; splints; surgical and orthopedic appliances; compression support stockings (e.g., Jobst) up to four pair per calendar year; catheters; syringes; and formulas for the treatment of phenylketonuria. The plan may elect to provide benefits for a less costly alternative item.

Benefits are not provided for:

1. Supplies purchased or dispensed when a plan benefit is not in effect or when the patient is not covered under this plan.
2. Items purchased or used more frequently than considered reasonable by the plan.
3. Incontinence supplies, ear plugs, enemas, alcohol swabs, cotton balls, or like supplies.
4. Freight, postage or delivery charges.
5. Compression support stockings (e.g., Jobst) in excess of four pair per calendar year.
6. Items that are normally part of the room and board charge at an inpatient facility.

Previous Policy

Oral Surgery

90% Network and 80% Non-Network

Benefits are provided for services and supplies performed by a physician or dentist for the treatment of the tissues of the mouth. This includes treatment for the following medical conditions:

• Excision of a tumor or cyst of the jaw, cheek, lips, tongue, or roof or floor of the mouth.
• Excision of exostosis of the jaw and hard palate.
• Incision and drainage of cellulitis.
• Incision of accessory sinuses, salivary glands or ducts.

Benefits are not provided for:

1. Services or supplies in connection with the correction of acquired developmental or congenital abnormalities of the jaw, or malocclusion of the jaw by orthognathic surgery with or without bone grafting, or vestibuloplasty performed by a physician or dentist, except as provided for under Orthognathic Surgery and TMJ and MPDS Treatment.
2. Extraoral grafts (grafts from tissues outside the mouth or using artificial materials) or tooth transplants.

Previous Policy

Orthognathic Surgery

50% Network and Non-Network

The Orthognathic Surgery Benefit Is Not Available Under Retiree Coverage

Benefits are provided for services and supplies provided by a physician or dentist for orthognathic surgery. Services and supplies are covered at 50 percent with a lifetime maximum of $5,000. These services always require 50 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or the $4,000 annual out-of-pocket maximum.

For the purpose of this plan, orthognathic surgery or surgical orthodontics refers to those elective surgical procedures necessary to correct the malposition of the maxilla (upper jawbone) or the mandible (lower jawbone). Treatment is covered when necessary to correct the following: a congenital defect or anomaly with severe functional or skeletal discrepancies; or trauma leading to an acquired defect with severe functional or skeletal discrepancies to the maxillofacial complex. Surgical treatment must be in association with conventional orthodontics. Covered services and supplies include:

• Examinations, laboratory services, x-rays, the administration of general anesthesia, the surgical procedure(s), and any complications thereof.
• Hospital or outpatient surgical services and supplies including surgical splints, stents and appliances.

Benefits are not provided for:

1. Any service or supply primarily for cosmetic purposes including any direct or indirect complications thereof.
2. Any treatment for a relapse of a previous orthognathic surgery.

Previous Policy

Orthotics

90% Network and 80% Non-Network

The Orthotics Benefit Is Not Available Under Retiree Coverage

Benefits are provided for services and supplies prescribed by a physician for custom-made foot orthotics constructed of acrylic, plastic or metal, with a maximum of $400 paid in any two consecutive year period. Covered services include the custom-made device which must be worn at all times that shoes are worn and not just for specific activities. Physician services, including impression casting, are paid under a separate benefit.

Previous Policy

Physician Services

90% Network and 80% Non-Network

Benefits are provided for services and supplies provided by a licensed physician covered under this plan as defined here. Each patient is responsible for the office visit copayment(s) when an office visit is billed. Covered services include:

• Physician visits.
• An eye examination (including refraction) performed in conjunction with a medical condition such as diabetes, glaucoma and cataracts.
• Hearing exams to determine the presence of an illness, injury or other hearing loss. The plan covers exams by physicians and audiologists.
• Injectable legend drugs administered in a physician’s office that are used to treat a covered condition.
• Surgical procedures (please see below).
• Adult immunizations required for certain exposures.
• Chemotherapy, radium therapy and other radioactive-type therapies.
• Allergy testing.
• Antigen and allergy vaccines or serums.

Surgery

Benefits are provided for covered services performed by a physician in:

• A physician’s office.
• An approved outpatient or same-day surgical center.
• An approved ambulatory surgical center.
• An approved hospital.

The plan uses accepted professional guidelines as developed by the American Medical Association (AMA) and other professional and governmental entities to determine the maximum allowed fee for specific surgical procedures, assistant surgeon’s fees, post-operative care, and multiple surgical procedures. When two or more procedures are performed during one operation, secondary procedures may be reimbursed at reduced amounts. Additional surgical procedures that are performed as a part of the total procedure or are “incidental” to the procedure, and pre- and post-operative care by the operating surgeon (except to the extent it is already included in the surgeon’s fee) are not covered.

This plan does not cover general anesthesia or the use of a hospital, ambulatory surgical center or other surgical facility for surgical procedures commonly and primarily performed in a clinic or physician’s office.

Previous Policy

Pregnancy Care

90% Network and 80% Non-Network

Female Participant or Dependent Spouse

Benefits are provided for services and supplies for pregnancy-related conditions for the female participant or the participant’s spouse. Covered pregnancy-related conditions include normal delivery, cesarean section, spontaneous abortion (miscarriage), legal abortion, and complications of pregnancy subject to the maximum allowable fee. Covered services and supplies include:

• Outpatient and inpatient hospital prenatal and postnatal care.
• Prenatal diagnosis of congenital disorders of the fetus by means of screening and diagnostic procedures during pregnancy. Genetic testing must be preauthorized.
• Childbirth in an approved birthing center that is licensed as required by the state in which it operates.

Pregnancy care by a physician, licensed midwife or certified nurse midwife is covered under this benefit.

Benefits are not provided for:

1. Postpartum home help or visits.
2. Pregnancy related charges incurred by a covered person who is a surrogate mother for another party, or for a person who acts as a surrogate for a person covered under this plan.
3. A dependent daughter’s pregnancy or resulting childbirth, miscarriage or abortion including complications thereof, except as provided for preventive care under the Patient Protection and Affordable Care Act.

Newborn Care

Benefits are provided for services and supplies for routine newborn care for a dependent child during the child’s initial confinement at birth. The newborn must satisfy his or her annual deductible and coinsurance requirements. Covered services and supplies include:

• Routine hospital services and supplies while the mother is in the hospital.
• Physician services.
• Circumcision during the initial hospitalization or in the physician’s office thereafter.

Services are not provided for any charges related to a child of a covered person acting as a surrogate mother for another party.

Previous Policy

Preventive Health Services

100% Network and 80% Non-Network

Benefits are provided for preventive health services including periodic health and cancer screenings, well-childcare, and certain vaccines and immunizations. To view a complete list of Affordable Care Act recommended preventive services for adult men, adult women and children, please refer to http://www.healthcare.gov/preventive-care-benefits. Services provided by network providers are not subject to the annual deductible, coinsurance or office visit copayment. Services provided by a non-network provider are subject to the annual deductible and office visit copayment and are subject to the maximum allowable fee as determined by the plan. Preventive health services for Medicare-eligible retirees are processed at the network level.

Previous Policy

Prosthetic Devices and Artificial Limbs

90% Network and 80% Non-Network

Prosthetic Devices

Benefits are provided for prosthetic devices that replace all or part of an internal body organ (including contiguous tissue) or that replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Examples of items and equipment that are considered prosthetic devices are:

• Cardiac pacemakers.
• Devices that replace all or part of the ear or nose.
• Colostomy bags and other ostomy equipment.
• Urinary collection systems with or without a tube for cases of permanent incontinence, and Foley catheters.
• Joint implants.

Replacements, repairs and adjustments are not covered until five years have elapsed, unless medical necessity is proven as described below:

• The prosthesis must be replaced because of changing fit or poor function.
• It costs less to buy a new prosthesis than to repair the old one.

Prosthetic Lenses

The term “internal body organ” includes the lens of an eye. Prostheses replacing the lens of an eye include postsurgical lenses customarily used during convalescence from eye surgery in which the lens of the eye was removed. Permanent lenses are also covered when required by a patient lacking the organic lens of the eye because of surgical removal or congenital absence.

When intraocular surgery is performed and the natural lens is removed, this plan covers, as a medical benefit, the reasonable cost of the initial contact lens or pair of eyeglasses when used to replace the natural lens. The “reasonable cost” means the cost of the new lens and any necessary services incident to the placement of the contact lens. “Initial” means only the first contact lens or eyeglasses that replaces the natural lens, and not any other that might be required at a later date because of a change in visual acuity. This benefit may apply to treatment of the following medical conditions:

• An injury to intraocular structures of the eye which requires the removal of the lens of the eye.
• Keratoconus.
• Keratitis sicca or bullous keratopathy (dry eye).
• Sightless and shrunken by inflammatory disease by the use of a shell (or shield).

For patients who are aphakic who do not have an intraocular lens (IOL), the following lenses or combination of lenses are covered when determined to be medically necessary: bifocal lenses in frames; lenses in frames for far vision and lenses in frames for near vision; or when a contact lens(es) for far vision is prescribed (including cases of binocular and monocular aphakia), benefits will be paid for the contact lens(es) and lenses in frames for near vision to be worn at the same time as the contact lens(es), and lenses in frames to be worn when the contacts have been removed.

Lenses which have ultraviolet absorbing or reflecting properties are covered in lieu of regular (untinted) lenses if it is determined that such lenses are medically necessary for the patient.

Benefits are not provided for:

1. Cataract sunglasses obtained in addition to the regular (untinted) lenses.
2. Anti-reflective coating and oversize lenses.
3. Scratch resistant coating.
4. Charges for deluxe frames.
5. Contact lens cleaning solution.
6. Normal saline for contact lenses.
7. Low vision aids.
8. Progressive lenses.
9. Presbyopia-correcting intraocular lenses.

Braces

Legs, arms, back, and neck braces, and trusses are covered expenses when prescribed by a physician. A “brace” includes rigid and semi-rigid devices used for the purpose of supporting a weak or deformed body part or for restricting or eliminating motion in an injured or diseased part of the body. Back braces include, but are not limited to, special corsets (sacroiliac, sacrolumbar, and dorsolumbar corsets), and belts. Orthopedic shoes are covered if an integral part of a leg brace.

Benefits are not provided for:

1. Elastic stockings (excluding compression support stockings), garter belts or similar devices.
2. Freight, postage or delivery charges.
3. Routine upkeep.

Artificial Limbs

Artificial legs, arms, and eyes are a covered benefit when prescribed by a physician. A terminal device is also covered regardless of whether an artificial arm is required by the patient. Stump stockings (up to four per calendar year) and harnesses (including replacements) are also covered when these appliances are essential to the effective use of the artificial limb. Adjustments to an artificial limb or other appliance required by wear or by a change in the patient’s condition are covered when ordered by a physician. Replacements and repairs are not covered until five years have elapsed unless medical necessity is proven.

Benefits are not provided for:

1. A prosthesis or artificial limb ordered when a plan benefit is not in effect or when the patient is not covered under the plan.
2. Freight, postage or delivery charges.
3. Routine upkeep.

Wigs and Hairpieces

One wig or hairpiece for a patient who has lost hair as a result of chemotherapy or radiation therapy. The maximum the plan will pay for a wig or hairpiece is $550. Benefits are not provided for hair weaves or hair implants.

Previous Policy

Reconstructive Surgery

90% Network and 80% Non-Network

Benefits are provided for services and supplies provided by a physician for reconstructive surgery, meaning any operative procedure, any portion of an operative procedure or any other treatment performed for the purpose of improving or restoring a functional impairment which is defined as a state in which the special, normal or proper action of any body part or organ is damaged.

Benefits are not provided for cosmetic surgery (including any direct or indirect complications) meaning any operative procedure, any portion of an operative procedure or any other treatment performed primarily for the purpose of improving or reshaping structures of the body in order to enhance the patient’s appearance and self-esteem and is not needed to correct or improve a bodily function. The following examples of what are not covered: surgery for sagging skin of the eyelids (blepharochalasis), face, neck, abdomen, hips, or extremities (meloplasty, rhytidectomy or lipectomy); breast augmentation, cosmetic reduction or uplift procedures; gynecomastia; reshaping of the nose (rhinoplasty) or ears (otoplasty); or silicon or collagen injections; or cosmetic laser procedures to any part of the body.

Reconstructive Breast Surgery

Benefits are provided for services and supplies provided by a physician related to initial reconstructive breast surgery following or coinciding with a mastectomy that is performed as a result of an illness or injury. In accordance with the Women’s Health and Cancer Rights Act of 1998, such benefits include reconstruction of the breast on which the mastectomy was performed, surgery on the other breast to produce symmetrical appearance, and prosthesis and treatment of physical complications at all stages of mastectomy, including lymphedemas. One external prosthesis is covered each calendar year and two mastectomy bras are covered every six months.

Breast reconstructive surgery to correct breast asymmetry is not considered medically necessary except for:

• Poland syndrome, in conjunction with surgical correction of chest deformity; or
• Repair of breast asymmetry due to a medically necessary mastectomy; or
• Prompt repair of breast asymmetry due to trauma.

Benefits are not provided for reconstructive breast surgery for complications arising from a cosmetic procedure such as augmentation or reduction mammoplasty.

Previous Policy

Rehabilitative Care

90% Network and 80% Non-Network

The benefits described below are provided for rehabilitative care when prescribed by the patient’s attending physician and are medically necessary to improve or restore function previously normal but lost due to illness, injury or surgery.

Inpatient Care

Benefits are provided for a semiprivate room in a hospital with a rehabilitation department or a rehabilitation hospital. Inpatient admissions are covered for physical, speech, respiratory, and occupational therapy services and supplies, with an annual maximum of 15 inpatient days. If, however, the ordering physician determines additional visits are medically necessary, a fully documented request can be made to the plan. Up to an additional 15 visits may be allowed (a total of 30 visits per calendar year) based on the information provided by the ordering physician to the plan. This benefit maximum includes physician visits, medical supplies, and the services of the physical, speech, respiratory, and occupational therapist, and applies to habilitative and rehabilitative services combined. All care must be part of a written plan of multidisciplinary treatment prescribed and periodically reviewed by the attending physician. Precertification is required for a separate inpatient admission or for an admission that is part of a continuous inpatient stay that began with acute care. Inpatient care is only covered when services cannot be provided in a less intensive setting.

Outpatient Care

Benefits are provided for physical, speech, respiratory, and occupational therapy when performed by a physician or physical, speech, respiratory, or occupational therapist in the office, clinic or outpatient hospital department with a calendar year maximum of 30 outpatient visits. If, however, the ordering physician determines additional visits are medically necessary, a fully documented request can be made to the plan. Up to an additional 30 visits may be allowed (a total of 60 visits per calendar year) based on the information provided by the ordering physician to the plan. This benefit maximum applies to habilitative and rehabilitative services combined. All care must be part of a formal program prescribed by the attending physician. Therapy must be provided under the physician’s supervision and the patient must continue under the care of the physician during the time the therapy is provided. In addition, the physician must periodically evaluate the treatment plan and certify that continuing therapy is required.

Biofeedback is covered within the provisions of the outpatient rehabilitative care benefit (included in the calendar year 60 outpatient visit maximum) but only when it is necessary for muscle reeducation of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm or weakness (i.e., incontinence), and more conventional treatments (i.e., heat, cold, massage, exercise, and support) have not been successful.

Exercise programs for cardiac patients, commonly referred to as “cardiac rehabilitation,” are covered within the provisions of the outpatient care benefit (included in the 60 outpatient visit calendar year maximum). Benefits are provided for phase II cardiac rehabilitation up to a maximum of 12 weeks or 30 sessions when provided by a hospital outpatient department or in a physician-directed clinic. Cardiac rehabilitation program benefits are available only for patients with a clear medical need who are referred by their attending physician and (1) have a documented diagnosis of acute myocardial infarction within the preceding 12 months, or (2) have had coronary bypass surgery, or (3) have stable angina pectoris. Phase III cardiac rehabilitation is not covered.

Benefits are not provided for:

1. Nonmedical self-help or related testing; work hardening; recreational, cognitive, behavioral, or vocational therapy; neuromuscular reevaluation; or gym or pool therapy.
2. Social or cultural therapy.
3. Acupressure or massage therapy.
4. Therapy elected by the patient but not prescribed by the attending physician prior to commencement of treatment.
5. Services related to activities intended to promote overall fitness, sports conditioning or overuse, flexibility or sense of well-being without direct relationship to restoration of a functional loss related to illness, injury or surgery.
6. Therapy provided to patients who have achieved their therapeutic goals; or therapy provided to patients whose progress in strength and mobility has reached a plateau, except as necessary to prevent deterioration.
7. Self-correcting dysfunction such as hoarseness, language therapy for young children with natural dysfluency, or oral myofunctional therapy; stammering and stuttering; sensory integration therapy; state-required medical assessments for specialized educational programs; or services or supplies required by law to be provided by any school system.
8. Feeding therapy.
9. Biofeedback for muscle tension states, psychosomatic conditions, tension and anxiety states, headaches, chronic pain, Raynaud’s disease, or hypertension.

These exclusions apply to both inpatient and outpatient services.

Previous Policy

<@3>Skilled Nursing Facilities

90% Network and 80% Non-Network

Benefits are provided for services and supplies related to skilled care in a Medicare-participating skilled nursing facility with an annual maximum of 25 days. Skilled nursing facility care must be part of a formal written treatment plan prescribed by the attending physician who certifies that the care is medically necessary and that the patient needs skilled nursing or skilled rehabilitative services on a daily basis. To qualify for this benefit, care in the skilled nursing facility must be provided in lieu of inpatient hospital care and the patient must meet the following two conditions:

• The patient's condition requires daily skilled nursing or skilled rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility.
• A physician certifies that the patient needs, and receives, skilled nursing or skilled rehabilitation services on a daily basis.

Covered services and supplies include:

• A semi-private room, meals and skilled nursing care.
• Services and supplies furnished and used while in the skilled nursing facility including, but not limited to, physical, speech, respiratory, and occupational therapy, routine laboratory tests, special treatment rooms, medical supplies, and drugs.
• Drugs, biologicals, supplies, appliances, and equipment for use in the facility and which are ordinarily furnished by the facility for the care and treatment of the patient.
• Physician visits and mobile x-ray charges.

Benefits are not provided for:

1. Custodial or maintenance care; nonmedical self-help or related testing; personal convenience items; vocational, educational, cognitive, or behavioral therapy; exercise programs; or therapy or maintenance which is solely for the purpose of slowing body degeneration rather than restoring functional improvement.
2. Services or supplies received after the date the attending physician stops treatment or withdraws certification.
3. Private duty nursing.

Services from a skilled nursing facility that are not usually provided by such facilities, or where the care given during the confinement is not expected to lessen the disability and enable the patient to live outside the facility.

Previous Policy

<@3>Sleep Studies

90% Network and 80% Non-Network

Benefits are provided for services and supplies related to sleep studies performed to diagnose illness or syndromes related to sleep, performed in sleep disorder centers or laboratories for evaluating sleep-related breathing disorders, which may be hospital affiliated or free standing.

Previous Policy

<@3>Sterilization

100% Network and 80% Non-Network

Benefits are provided at 100 percent for a vasectomy and a tubal ligation when services are received from a network provider. Benefits are not provided for the reversal of the surgical sterilization. If you have a vasectomy, this plan does not cover a facility fee or general anesthesia.

Previous Policy

<@3>Telehealth Consultations

90% Network and 80% Non-Network

Telehealth or telemedicine medical service are covered. Services may be delivered by online video or telephone to help you see your doctor or other provider from home instead of at a medical facility.

These services are subject to the annual deductible, the office visit copayment and coinsurance. Covered services are limited to those services that would be covered by the plan if the same services were received at a medical facility. Virtual care must be provided by a licensed provider operating within the scope of his or her license.

Previous Policy

<@3>TMJ and MPDS Treatment

50% Network and Non-Network The TMJ and MPDS Benefit Is Not Available Under Retiree Coverage

Benefits are provided for services and supplies for the treatment of temporomandibular joint dysfunction or disease (TMJ) and myofascial pain dysfunction syndrome (MPDS). Covered services include treatment to diagnose, prevent or correct malfunction, degeneration, disease, injury, and all other ailments or defects (congenital or hereditary) related to the joints, muscles and tissues that connect the jaw to the skull, with a lifetime maximum of $2,500. These services always require 50 percent coinsurance and these coinsurance expenses do not apply toward the $2,300 annual coinsurance maximum or the $4,000 annual out-of-pocket maximum. Benefits are provided for:

• Examination and x-rays.
• Hospital services and supplies, and the services of a physician or dentist, including the administration of general anesthesia.
• Behavior modification including counseling, bruxism appliances and biofeedback.
• Repair and regeneration including:
  • Physical therapy in the form of heat, ultrasound, electrical muscle stimulation, exercises/muscle retraining, and anesthetic injections.
  • Restorative dentistry for TMJ/MPDS purposes.
  • Mandibular repositioning appliances including splint therapy, bite planes and orthopedic stabilizing appliances.
  • Equilibration.
  • Prosthodontic dentistry.
  • Surgical procedures including related hospitalization.
  • Braces or retainers for tooth movement to stabilize the occlusion.

Benefits are not provided for services or supplies that are educational or experimental in nature, provided primarily for the purpose of medical or research purposes, or include treatment for restorations of the dentition, supporting tissues and bone. Procedures and instrumentation must be approved by the American Dental Association.

Previous Policy

<@3>Transplants

90% Network and 80% Non-Network

Benefits are provided for the services and supplies of a covered transplant at an approved transplant facility as described below. Authorization is based on the patient's medical condition, the qualifications of the providers, appropriate medical indications for the transplant, and appropriate, proven medical procedures for the type of condition (in other words, not experimental in nature and within the standards of generally accepted medical practice as determined in the sole and absolute discretion of the Board of Trustees). All approved transplants must be performed at a Medicare-approved transplant center or within a Joint Commission On Accreditation of Hospitals (JCAHO) hospital with a Medicare-approved transplant program.

<@3>Cord Blood Stem Cells

Transplantation of cord blood stem cells from related or unrelated donors is considered medically necessary when the recipient is a child, adolescent or young adult with an appropriate indication for allogeneic bone marrow transplant but without a hematopoietic stem-cell donor. Collection and storage of cord blood from a neonate is considered medically necessary when an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the possible need for allogeneic transplant.
Prophylactic collection and storage of cord blood from a neonate is not considered medically necessary when proposed for unspecified future use as an autologous stem cell transplant in the original donor, or for unspecified use as an allogeneic stem cell transplant in a related or unrelated donor.

Donor Benefits

Donor procurement costs are available if the transplant recipient is covered for the transplant under this plan. Donor procurement benefits are limited to selection, removal of the organ or tissue, storage, transportation of the surgical harvesting team and the organ or tissue, and such other medically necessary procurement costs as determined by this plan. Donor benefits are not provided when they are available through another health care plan, when the donor is eligible under this plan and the recipient is not, or for donor and procurement services and costs incurred outside the United States, unless specifically approved by Carpenters Trusts.

<@3>Centers of Excellence Program

The Centers of Excellence Program includes a national network of participating facilities and physicians for transplants and transplant-related services, including evaluation and follow-up care. The following travel expenses benefit is only provided if you receive care at a participating Center of Excellence.

Travel Expenses

For Transplants, Gene Therapy and Adoptive Cellular Therapy Only
If the facility is more than 100 miles from the patient's residence, certain travel and lodging expenses for the patient and one companion may be reimbursed if preauthorized. Travel is reimbursed between the patient's home and the facility for round trip (air, train or bus) transportation costs (coach class only). If traveling by auto to the facility, mileage, parking and toll costs are reimbursed.

• Lodging reimbursed at a rate of $50 per night per person (maximum $100 per night).
• Overall travel and lodging reimbursement limited to $10,000 for any one procedure treatment or type.

No other travel expenses will be reimbursed. Travel expenses will not be provided if the same service can be obtained locally from a Transplant Network facility or provider.

Limitations and Exclusions

Benefits are not provided for:

1. Transplants not provided in a Medicare-approved transplant center or within a JCAHO hospital with a Medicare approved transplant program.
2. Nonhuman, artificial or mechanical transplants.
3. Experimental or investigational services or supplies as defined by this plan.
4. Services in a facility not approved by this plan.
5. Stem cell support and high dose chemotherapy associated with stem cell support, except as specified by this plan.
6. Services and supplies for the donor when the donor benefits are available through other group coverage.
7. Expenses when government funding of any kind is provided.
8. Expenses when the recipient is not covered under this plan.
9. Donor and procurement services and costs incurred outside the United States.
10. More than one retransplant if the transplant was not successful.