Summary Plan Description

Durable Medical Equipment

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

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 precertified, 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.